Firstly, my apologies for taking so long to get this back on track, we moved to our new house at the end of November so I spend my weekends barrowing dirt around the place. I’ve also rather foolishly agreed to work part-time for the local mental health service as they were short of staff. Now I know why they’re short of staff. Actually, it’s good experience, I’ve been out of the government for nearly twenty years. If anything, government mental health services are worse than they were back then.

Stimulants in Childhood

The medicalisation of childhood proceeds apace. A report from the US Center for Disease Control, published in the Journal of the American Academy of Child and Adolescent Psychiatry (November 2013)showed that the numbers of American children taking stimulants continues to rocket: “11% of 4-17yr olds were reported by their parents to have received an ADHD diagnosis from a healthcare provider, a 42% increase from 2003-04 to 2011-12.” This translates as 6.5million children, with over half of them (3.5mln) taking highly addictive drugs during their formative years. Needless to say, the rates of this “genetic disease” vary quite dramatically, from as low as 4% in Nebraska to 15% in Arkansas and Kentucky. In 1977, there were 400,000 children in the US taking these drugs; I remember that figure because in that year, there were 400 children in the Netherlands taking them. By 1990, it was 600,000 and the numbers just keep going up. Fortunately, it is starting to dawn on some of the experts that this isn’t necessarily a good thing. One of them, Prof. Keith Connors, a psychologist at Duke University and developer of the widely used rating scale bearing his name, said: “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”

In fact, genetic diseases don’t increase by 900% in one generation, so something else is happening. For an example of that “something else,” look no further than this gem: a New Disease. Not satisfied with snagging 15% of the juvenile population and putting them on drugs, at a national cost of about $9billion a year, the bounds of pathology are to be stretched again, further eroding the concept of normality. Psychiatrists and psychologists have decided that the quiet little day-dreamers in school are mentally ill: “Called sluggish cognitive tempo, the condition is said to be characterized by lethargy, daydreaming and slow mental processing. By some researchers’ estimates, it is present in perhaps two million children.”

It is early days yet, though, and people involved in the push to have this condition recognised as a mental disorder are still working out the diagnostic criteria. One author, who has put the condition in Wikipedia, defined the symptoms as: “prone to daydreaming, difficult staying awake or alert in boring situations, easily confused, easily bored, spacey or in a fog, lethargic or more tired than others, underactive or less energy than others, slow moving, don’t process information as quickly or accurately as others.” The same author “has also published a symptom checklist for mental health professionals to identify adults with the conditions; the forms are available for $131.75 apiece.”

Needless to say, Big Pharma is watching closely, ready to offer their usual drugs to help the sufferers. At $10.00 a day per child, it would be a windfall of $7billion a year for the drug companies, especially as it would cost nothing to ramp up production. But who would get the drugs? Bored children? I was bored senseless for twelve years of school, and couldn’t stay awake in university lectures. I was certainly a day-dreamer and underactive at school because I worked six days a week and studied late each night. But it would also snare all unhappy children, children who were kept awake half the night by brawling or drunken parents or who didn’t get a proper breakfast, children who were cold, sick, partly deaf, nervous of the teachers or the other children and so on.

It’s just another example of psychiatrists needing to invent a new disease if they want to get fame and lots of research grants from the drug companies.

The Actual Cost of Pharmaceutical Ingredients

Talking of drug companies, a lady called Sharon L Davis, a Budget Analyst at the US Dept of Commerce, put an article on line regarding the actual cost of ingredients used to produce standard medication. Here are some of her figures:

Drug name

Dose

Consumer price (100 tablets)

Cost of active ingredients

Percentage markup

Celebrex

100mg

$130.27

$0.60

21,712%

Claritin

10mg

215.17

0.71

30,306%

Keflex

250mg

157.39

1.88

8,372%

Lipitor

20mg

272.37

5.80

4,696%

Norvasc

10mg

188.29

0.14

135,493%

Paxil/Aropax

20mg

220/27

7.60

2,898%

Prevacid

30mg

44.77

1.01

4136%

Prilosec

20mg

360.97

0.52

69,417%

Prozac

20mg

247.47

0.11

224,973%

Tenormin

50mg

104.47

0.13

80,362%

Vasotec

10mg

102.37

0.20

51.185%

Xanax

1mg

136.79

0.024

569,958%

Zestril

20mg

89.89

3.20

2809%

Zithromax

600mg

1482.19

18.78

7,892%

Zocor

40mg

350.27

8.63

4,059%

Zoloft

50mg

206.87

1.75

11,821%

Two things to remember: First, I can’t vouch for her figures but they are probably reasonably accurate. The actual cost of the active ingredients in medication is trivial. If you buy Winthrop Panadol in the supermarket, you will pay about 25c per tablet. If you buy the same ingredient (paracetamol/acetaminophen) in the cheap version, you can get them for under 2c per tablet. That’s 1050% more for exactly the same drug, possibly made in the same factory. In Asia, those drugs sell for about 0.5c per tablet and still make a profit. In the US, Walgreens sell Tylenol for about $0.36 a tablet while their own brand acetaminophen sells for 11c a tablet, only about 330% markup.

Second point: in the US, drug prices are protected by the Medicaid amendments pushed through by the Bush Administration. This blocked government agencies from using their purchasing power to get lower prices of drugs, as happens everywhere else in the world. Those prices are much higher than anybody pays in Australia, Canada, the UK etc, but the profits are still outrageous. Also, all consumer prices of drugs in Australia are capped at $37.50 per prescription, so it doesn't matter how much it costs the government, the patient pays only that amount. Pensioners pay a maximum price of $6.20 per script regardless. I've put more of these details in an article in Truthout (and don't tell me about the error in the title, I know).

The Question of ECT

We have just gone through the drama of two states amending their mental health acts. I’ve mentioned West Australia before, they had the brilliant idea of permitting psychosurgery for children twelve and over if the child consented. Not the parents, they didn’t get a look in. If the child’s psychiatrist certified that his patient was sufficiently mature to understand the nature of the operation, then it could go ahead, even against parental wishes. Fortunately, that bit of lunacy was dropped but the battle then moved to ECT. I sent this letter to every politician in the Victorian and West Australian parliaments arguing that they should oppose any move to loosen restrictions on ECT. It helped but wasn’t entirely effective:

People who advocate wider use of electro-convulsive therapy (ECT) often point to the position statement issued by the Royal Australian and New Zealand College of Psychiatrists to justify their views. Despite the widespread misunderstanding, this is not a scientific statement; it is a consensus opinion derived by an overtly political process. It draws on some scientific facts but not all.

“The statement asks a series of questions such as whether it is safe (generally) and effective (in the short term) or who should do it but the one question it does not pose is this: Is ECT necessary? It must be understood that many psychiatrists do not use it at all, that its use varies dramatically from one hospital to another, or one part of the country to another. Some practitioners use it so commonly that it is almost routine; others, practicing in the same setting seeing a similar if not identical population of patients, never use it.”

I have practiced psychiatry in some of the most difficult parts of this country for 37yrs without using ECT. In two hospitals to which I was appointed chief psychiatrist, one for five years and one for three, ECT was used prior to my taking up my appointment. It was not used for the time I was in charge, then it was started again some time after I left. This says that while ECT is a treatment option, it proves emphatically that ECT is not “(an) essential treatment option that should be available to all patients in whom its use is clinically indicated.”

“For some practitioners, ECT is close to the first treatment option considered. For many others, treating the same types of cases, its use is never “clinically indicated.” It is of interest that in both hospitals, during my total of 8 years as chief, the admission rates, bed occupancy rates and duration of stay all dropped, only to rise again after I left. This is despite the lack of use of ECT. The notion that ECT achieves some therapeutic goal not available by other means is simply not true in my experience.

The RANZCP statement on ECT says that patients should give informed consent. Strictly, this should include patients being told that some psychiatrists use ECT a great deal, while others rarely or never use it, and it is a matter of chance to which psychiatrist the patient has been referred.

“Parliaments should impose more restrictions on ECT, not loosen them.”

You might expect that the college would start whining about disrespect or some such rubbish but they usually know when to shut up and say nothing. Pity.

Highlighted Books and Articles

Flaws in the Serotonin Hypothesis of Depression

In this newsletter I want to address the serotonin hypothesis of depression as for years we’ve been hearing that depression is associated with low levels of serotonin (which has been used to support the biological basis of psychiatric disorders). In fact, the evidence for this claim is skimpy. An outstanding review by Jeffrey Lacasse, published in PLOS, is essential reading for anyone who prescribes these drugs. He reviews the evidence and shows that numerous researchers, including Stephen Stahl, the author of the most widely circulated psychopharmacology textbook in the US (Essential Psychopharmacolgy), do not make this claim. Stahl’s textbook states “So far, there is no clear and convincing evidence that monoamine deﬁciency accounts for depression; that is, there is no “real” monoamine deﬁcit.”

Additionally, Robert Whitaker shows in his book, Anatomy of an Epidemic, that the findings of low serotonin were published in patients who were already on treatment with agents with serotonin re-uptake properties. He argues that this does not prove a primary imbalance but gives evidence to show this is a homeostatic effect (ie blocking degradation of serotonin via SSRIs/TCAs maintains higher levels of serotonin which signals the body to makes less serotonin to circumvent this chemically induced imbalance). Per his review of the literature he cannot find a study which prospectively shows that SSRI/TCA naive individuals who develop depression have this imbalance.

If you doubt the “Teflon” claim, a paper by McCabe et al, published in Biological Psychiatry (2010) shows that SSRIs diminish neural processing of both aversive AND positive stimuli. In fact, it has emerged they have major side effects but drug companies carefully suppressed this information. The list of side effects includes confusion; headaches; anorgasmia leading to loss of libido; severe agitation with or without suicidal ideas; dependency, and severe withdrawal states.

SSRIs may also help people with severe depressive states but it is clear that the lower the level of depression, the more the risk-benefit ratio skews towards the risks. The sexual side effects, including complete anorgasmia, are seriously under-appreciated (see figure 1). They affect the majority of patients on some level, with 30-50% rate of anorgasmia. This is very troublesome, especially in young men who can panic over it in case they have been permanently damaged or, in a few extreme cases, that they may be changing their sexual orientation. Anxiety over diminished sexual performance can add very substantially to trouble between couples and is just another way drugs can make people worse off.

I always list the side effects of psychiatric drugs before prescribing them: Rapid weight gain (many antipsychotics, mirtazapine), marked cognitive deficits and confusion (benzodiazepines, see figure 1), drowsiness, lethargy and inertia (worst with dopamine antagonists), difficulty in achieving or absence of ability to orgasm (SSRIs), habituation which results in severe withdrawal effects (all classes). Strangely enough, few want them when they hear that list. However, an astounding proportion of patients who have had them in the past were told by the physician: “These drugs have no side effects.” This comes straight from the drug company handouts but the remarkable thing is how physicians are able to convince themselves it’s true. I see people every day who have gained massive amounts of weight from these drugs (especially olanzapine), such as 38kg in 20 months, 42kg in 30 months and so on.

While I still use SSRIs I do so at a substantially lower rate than my peers (I’m in 8th percentile for prescription rate in Australia). I recommend the next time you’re about to prescribe an SSRI/SNRI you ask yourself if the patient’s depression is bad enough to take a 50/50 chance at ruining their sex life.

Q&A

Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month.

Do you ever feel the need to go back somewhere to see how your past is faring? Normally, I don’t. I don’t like going backwards but I’ve had an interesting few months lately doing a locum for the local mental health services security unit. Going through the doors is like going back forty years, the only real differences are that nurses don’t wear uniforms now and the keys are electronic. Apart from that, and the piles of forms that staff have to fill in every day, nothing has changed. All too often, patients have been in and out of the unit (mostly in) for years, if not decades, but nobody has ever taken a proper history. They are heavily drugged and are put in seclusion (solitary) or even shackled on the perception that they may be dangerous. The whole place is based on the idea of managing risk, but not a risk the patient may represent to anybody in particular, only the risk that he may do something that will embarrass the department and thence the minister. Patients spend the day pacing up and down, bored to distraction, while staff spend all their time sorting out who has to be escorted where at what level of security. There are no activities, no workshops, limited facilities for exercise and so patients spend all their time working out how to smuggle cigarettes in since smoking has been banned in the hospital.

The problem is that the psychiatric staff see their role as diagnosing mental illnesses and prescribing drugs. End of story. The weekly ward meeting is mainly a matter of staff complaining about how a patient is “escalating” and needs more drugs, while the rest of the time is spent working out how to discharge somebody to other centres without any risk of “blow back” (an expression filched from American war movies, I’m told) in the form of the patient doing anything wrong that could possibly be blamed on the unit. Patients have to be packaged as saleable commodities before the other places will take them, so it’s a bit like a jumble sale where everybody sits around trying to find something nice to say or how to get some government grant or other to make the poor soul more attractive.

It’s an interesting experience but the essential point I’m learning (actually relearning) is that all the government interventions over the past twenty years to improve mental health services have gone nowhere. Sure, the amount of money spent per head of population has tripled or even quadrupled; the gigantic old “looney bins” have all been closed and their land sold for suburban developments; most patients sleep in single rooms, often with their own bathrooms; the food is better and so on but the biggest change is the vast bureaucratization of what should be a caring profession. In the old days, if a medical practitioner believed a person was mentally ill and a danger to self or others, there was one form to fill in. One page. If the patient refused to let his relatives take him to hospital, two more forms had to be signed and witnessed by a justice of the peace, ordering the police to pick him up. The first form took about two minutes to complete while the other two took about half an hour, with traveling time.

These days, it takes a cast of thousands because, you see, his human rights must be protected. So there are half a dozen forms to fill in, half a dozen interviews under conditions of some coercion, then there is the mental health tribunal. This is a duly-constituted, semi-judicial body that reviews every order made under the Mental Health Act, authorises treatment and reviews each patient every six months. For this, six to ten page reports must be prepared and circulated to the tribunal for their edification. It soon reaches the point where psychiatrists spend more time writing reports than they do seeing patients.

Then the big day arrives, the patient is escorted to the hearing room by three or four hefty nurses and sits before their eminences on the tribunal. The chairman of the tribunal is a lawyer, and the others consist of an independent psychiatrist and a community member, most often a nice middle-aged lady with a mentally disordered relative. In addition, the patient has a person called a patient’s advocate, who takes his side, and a senior lawyer from the attorney-general’s department who represents the “interests of the community,” for which everybody understands the government. The cast varies from place to place. Some states, the tribunal is a quasi-judicial hearing conducted by a magistrate, or even a duly constituted mental health court. Some places provide a legal aid lawyer to represent every patient, some get a social worker and others can pay for their own lawyer if they wish. That’s at least ten people, all of them being paid handsomely, except the patient.

After everybody is seated and duly introduced (it makes it seem less formal but I suspect it’s just to waste more time), the psychiatrist has to state the facts of the matter, followed by an opinion as to whether the patient is mentally ill (note that word) and dangerous to self or others. Some places even allow a person to be detained on the basis he is likely to damage his reputation, even when his reputation is as the town lunatic. Most times, the patients say nothing, either staring at the floor in some sort of bemused stupor, or gazing out the window, bored to distraction. Others are old hands at this game and challenge every word the psychiatrist says, which means the chairman has to try to quieten them without the confidence that comes from being able to chuck malcontents into the cells to shut them up. So, after an hour or two of highly expensive to and fro, everything the hospital asked for in terms of banging the patient away for six months and pumping him full of drugs while locking him in a penitentiary, all is approved, down to how many hours per week he can walk in the hospital grounds with or without escorts (I am perfectly serious), and he is shunted back to the wards for a cup of tea (but not a smoke). The whole thing is a charade.

These medieval exercises in semi-judicial self-deception were dreamed up by lawyers who decided that a single psychiatrist signing an order was an affront to the patient’s human rights. Thus, the incredibly simple and cheap old system had to be swept away in favour of a vast expansion of the growth industry of legalised mental health. We could go on about how much it costs (the Queensland Mental Health Tribunal spent $8,029,000 in 2010-11), how much better it would be if that money were spent on providing more housing for the mentally-troubled, or how it diverts psychiatry from a caring profession into some sort of cryptic forensic bungle, but one vitally important and oft-overlooked point is this. In the Good Old Days, one medical officer signed the form. His name was on it, and his address. If he got it wrong, the patient could sue him. Therefore, as junior medical officers, we made sure we didn’t get it wrong. We erred on the side of caution, meaning we preferred to make false negative errors rather than false positive. That is, it was better to say somebody was not mentally ill when in fact he was, than to mistakenly say he was crazy when he wasn’t.

No great harm came from giving a person a few more days of freedom; if he was genuinely mentally troubled, he would come back one way or another. But putting the wrong person in a mental hospital could produce mental disorder, we all knew that. Today, the boot is on the other foot. Not detaining a person leads to more trouble, in terms of court cases and complaints to the Medical Board, than wrongly detaining a person and forcing him to take treatment he doesn’t need. Like, if he didn’t need treatment before he went into the mental hospital, he sure will after he’s been there a few weeks.

Compounding it, these days, even though gross abuses of psychiatry are just as common as they were forty years ago, there’s nobody for the patient to sue. Because nobody is accountable, everybody errs on the side of caution, of not being the person who let a crazy person loose. The reason nobody is responsible is because the modern system was designed by lawyers, and lawyers don’t like to be held responsible. In fact, they abhor responsibility and believe it is best spread around the system like a slime mould, hidden in the nooks and crannies of an arcane act that only they dimly understand, one that patients can’t even read, let alone understand. This means that responsibility cannot be pinned on a single person and everybody gets to sleep well at night. Except the patient, but he can be given more drugs if he protests.

But if nobody is responsible, we end up with a human version of the Tragedy of the Commons. This is an economic concept that says that if some good or property is held in common, then it is economically rational for everybody to get as much of it as they can before it runs out. Consequently, it runs out much quicker than if they rationed it. The other side of the coin is that people won’t care for something if they don’t have anything in the game, they will use it but not invest any time, energy or money in it. Common property is soon lost, stolen, wrecked, neglected or run into the ground. People never look after common property as well as they look after their own (just think of the tea room in your office, compared with the kitchen in your home), so the mental patient, who is common property in the modern mental hospital game, ends up like the sink in your office kitchen: everybody dumps on him and nobody remembers to clean up.

It turns out that a very large chunk of all the extra money being spent on psychiatry these days is spent on tribunals and committees and lawyers and review panels and nurses filling in forms that nobody reads (more on them next time) and social workers filling in half a dozen different ten page application forms to have patients moved to a hostel (they couldn’t use the same form), psychiatrists writing legalistic ten page reports analysing the patient’s static risk and vulnerability factors, and so on. As an example of institutionalised inefficiency, there are two parts to the security unit I’m working in, high security and medium security. The units are separate buildings, about a hundred metres apart. When we want to move a patient from one building to the other, guess how many meetings, involving how many people, over how many days, it takes? Answers at the end of this newsletter.

Dr Alan Frances, eminent critic of DSM-5, has been in the news lately. Firstly, after thirteen years gestation, DSM-5 finally saw the light of day. I haven’t seen it and, unless somebody gives me a free copy, I won’t, but Dr Frances has. Hardly had the cash registers at the American Psychiatric Association started ringing than Frances threw a stink bomb into the launch party. His critique has attracted a lot of attention but I’m afraid I haven’t seen that, either. Not much use reading it before reading DSM-5 itself, but if anybody else has read it and wants to send in a review, please feel free to hit the keyboard.

But he’s not the only critic taking aim at the APA’s misshapen offspring. The Book of Lamentations, one of the wittiest and most incisive critiques I have read in a long time, comes from a writer who describes himself as “a writer and dilettante surviving in London.” Sam Kriss has a website called Idiot Joy Showland, in which he skewers anybody silly enough to stick his head up while Kriss is around. Unfortunately for the APA’s legions of well-meaning but essentially ignorant journeymen on the DSM “Task Force,” Kriss was awake and on the prowl when they threw open the doors to their shop. They would have been better to pretend they weren’t ready.

Dr Frances also has an entry on his regular blog on Psychiatric Times, in which he describes a conference he recently attended.Overdiagnosis, held at Dartmouth College in September, was, he said, the most important conference he has ever attended. If that was the case, then it was the most important conference I’ve ever missed. I was scheduled to give a paper there but had to pull out because of family commitments. Damn, but you can’t win them all. My paper argued that the epidemics of bipolar disorder and ADHD are largely artificial, brought about by the insensate drive to prove that all mental disorder is brain disorder, coupled with the total absence of anything that approximates a biological model of mental disorder. You know what they say: If the only tool you have is a hammer, then everything looks like a nail. Same goes for psychiatry: if psychiatrists are paid to put people on drugs, then everybody will seem to have a biological disturbance of the brain. This is greatly aided by the fact that, these days, most psychiatrists, especially academic psychiatrists, can’t take a history.

Of course, they will say that they don’t need to take a history as the symptoms are all that counts, and symptoms are independent of the history, or context-free, in the modern idiom. Who says they are context-free? Academic psychiatrists, of course. So we have people who can’t take a history telling us that histories are irrelevant. But because they don’t have any real sense of what is normal, which you only gain by taking thousands of histories (and probably by leading a normal life after hours, which involves avoiding academics like the plague), everything seems crazy to them, so the boundaries of mental disorder keep spreading. There’s also the minor problem that any young psychiatrist who wants to make a for himself has to find a new field to plough. There’s no fame attached to being the thousandth person to realise that distressed people start to think of suicide, you have to find something to suck in the medical reporters in the media, because that’s the only way to start the ball rolling in the steeplechase for grants. Hence the cancer of overdiagnosis. I’ll be going to the next conference, in two years.

Talking of the steeplechase for grants, Dr Francis also Tweeted a shot at Australia’s Pride and Joy, the saintly Professor Patrick McGorry, he of the slightly tarnished halo: “Australia’s unproven, risky & premature prevention model goes for profit and markets internationally – http://t.co/XNW96qlnJ9″, quoth Dr Frances. McGorry’s highly lucrative efforts (like, turnover of hundreds of millions a year) to carve out the field of “Early Psychosis” are a textbook example of how academics manufacture new fields to plough. Luckily, this one failed to get in the DSM-5.

Question: How many psychiatrists are responsible for transferring a patient?

Answer: None, because nobody is responsible. In fact, it takes at least twelve people about fifty hours of reviewing the files, writing recommendations, filling in forms and so on, making dozens of phone calls, attending half a dozen meetings, writing memos notifying the superintendent and head office (in separate reports), the tribunal and various other worthies, spread over seven (that’s 7) days, to move one small body one hundred metres, out one gate and in another, trussed up in a van. That’s not even walking and enjoying the sunshine. Now who’s the mad one? If you want to read more on this, you can’t go past Erving Goffman’s classic, Asylums. (Actually, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, 1961). I read it in about 1974. Nothing has changed, only the forms.

Highlighted Books and Articles

FULL TEXT. Dorph-Petersen, K-A et al. (2005) The Influence of Chronic Exposure to Antipsychotic Medications on Brain Size before and after Tissue Fixation: A Comparison of Haloperidol and Olanzapine in Macaque Monkeys.Neuropsychopharmacology 30, 1649-1661. Internationally, antipsychotic drugs are very big business these days, like $50billion a year type big business. People are prescribed these drugs for a huge range of mental symptoms, and often for no symptoms at all. Indeed, the drugs are so omnipresent that US troops in battle zones are actually allowed to take them and still engage in combat (it’s different here: any member of the Australian forces who requires a psychotropic drug is stood down, so they don’t take them unless absolutely necessary). Children are prescribed as many as six or seven different major psychiatric drugs, and children in care get more than most. As Bob Whitaker showed in his Anatomy of an Epidemic, once people start these drugs, it is very difficult for them to come off them. Many of them never manage it. It is now absolutely normal to see people who have been taking drugs for thirty years. Good for the manufacturers, not so good for the people who were prescribed them, very often for the wrong reasons.

But not to worry, we are constantly assured by the drug companies and their tame professors that psychiatric drugs are good for you, they have no serious long term side effects and if they prevent one episode of psychosis, then it was all worthwhile. No side effects, if you overlook tardive dyskinesia and massive obesity, with all that it entails, among others. However, one serious side effect appears to have slipped under the radar, partly because nobody was looking for it and, when they found it, they thought it was something else. Chris Struble, of UCLA-Harbor Medical Center, in south Los Angeles, sent a link to a paper that should have sent shivers up the backs of most psychiatrists.

A group of researchers at University of Pittsburgh looked at the effects of two widely uses antipsychotic drugs, haloperidol and olanzapine, on rat brains. In a carefully-planned study, they fed the drugs to two groups of six macaque monkeys, with another group of six controls. They aimed at the usual plasma levels of the drugs seen in humans, and let the experiment run for over two years. At the end, they examined the unfortunate monkeys’ brains very closely. There was no doubt: the two antipsychotic drugs caused significant cerebral atrophy (almost 10% loss of weight). A disturbed monkey that was in the habit of chewing his hands and feet to the point of needing the lacerations stitched was put in the olanzapine group – to no effect. He kept chewing. We don’t know what other side effects were seen but we do know that the monkeys being fed the drugs didn’t like them and resisted taking them (how do you convince a monkey to take drugs he doesn’t like? Starve him).

Even today, I heard a senior nurse say “But he can’t be left without medication, we know psychosis causes brain damage.” Actually, that’s not true. We know there is an association between certain sorts of brain damage and psychotic states but mostly, it seems that the brain damage precedes the psychotic state, not the other way around. What we do know is that many of the drugs used so widely these days are themselves potent causes of brain damage. That puts a different light on them entirely.

Q&A

Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month. Thanks again to all who have submitted questions. Cheers,

I have to apologise, I’ve been busy with other things these two months, like making a living and building a house – in the mud. All good clean fun but this will have to be a bit shorter than usual.

A question from sunny California:

“My name is Alex and I am a PhD candidate at UC Berkeley in California. I wonder if you could answer a question about your thought-provoking 2011 paper

Cells, Circuits, and Syndromes

… What do you think about evidence from identical twin separation studies (e.g., showing the heritability of autism/schizophrenia) and examples of individuals who exhibit sharp personality changes immediately following traumatic brain injuries? Isn’t this evidence that mental disorders are the result of low-level biological abnormalities, at least in some cases?”(The reference is:

Cells, circuits and syndromes. A critique of the NIMH RDoC project. Ethical Human Psychology and Psychiatry13: 229-236. An expanded and much less polite version is available as Chap. 11 in my book from 2012, The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press).

There are several complex questions buried in this missive but first, in that paper, I don’t address the question of causation of mental disorder. All I say is that whatever NIMH think they’re doing with their concept of neural circuits, they won’t be addressing it, either. In fact, I’ve since found a statement from our good friend, Dr Thomas Insel, Director of NIMH and chief protagonist of the neural circuits/ Research Domain Criteria project (coming to you at stupefying cost) where he wrecks his own project for all time. He actually says what I have been claiming all along, that their project is not designed to understand the level of the brain at which mental disorder is generated. In a talk on TED from earlier this year, he specifically says we know that the form of the brain’s critical capabilities is not amenable to physiological analysis. Despite this, he is proposing to commit psychiatric research to basic neurophysiology for decades to come. This is not encouraging.

Let’s leave that for the time being and focus on the other important questions in Alex’s enquiry.

The question of how it is that people with brain damage show personality changes is, to me, self-evident:

IF the brain is a high-powered switching device (which it is) subserving the rapid, real-time manipulation of information (which it does) derived from a variety of sources (elementary neurophysiology) AND that information is important in determining how people behave (which I accept as true), THEN IT FOLLOWS that any physical agent that disturbs the brain’s switching functions (chemicals, infections, metabolic disorders, concussion, brain damage etc) will interfere with the observable behaviour.

If the change is temporary, like getting drunk, then the person will come back to normal tomorrow. If it is permanent, as in brain damage, then he will remain different as a result of the damage. If the damage involves frontal regions, then the highest cerebral functions will be involved, meaning judgement, discretion, subtlety etc. Unless somebody wanted to claim that human behaviour is unrelated to brain function, then I don’t see there is much room for dispute in this position.

HOWEVER, that’s not what psychiatry is about. Psychiatry isn’t about brain damage. I know orthodox psychiatry trumpets the “chemical imbalance” mantra but all my work says that (a) they have never defined what this could mean, and (b) I have argued that it is meaningless, anyway (which may go some way toward explaining why people like Dr Insel avoid the question). The crucial issue is this: Is it true that all mental disorder is necessarily due to an organic disturbance of brain function, or is there room for “something else”? I say there is room for something else, but the something else is not, as Daniel Dennett and Company assume, necessarily magic in nature. By invoking information processing as the “something else,” we escape the reductionist dead end of biological psychiatry and also sidestep the slippery problem of substance dualism, or what Dennett dismisses as green slime in the head. That is, there is a third way, a rational way, between boring biology and fanciful spirits. I don’t ever say there are no spirits, we just can’t deal with them in our present knowledge system.

So to move on: Can we explain mental disorder in terms of what people know and believe and hope? Yes, in principle, we can. It’s not difficult at all, it’s what is called the cognitive approach, which says that whatever people believe determines how they act and think and feel. Pretty simple. Now for the difficult question: Can we explain serious mental disorders in just these terms, or do we have to invoke biology to do that? I don’t believe we do. Firstly, there is absolutely no convincing evidence to suggest that there is a consistent biochemical, genetic or any other lesion in any significant mental disorder (I don’t count as mental disorders things like Lesch-Nyhan Syndrome, an exceedingly rare genetic defect that causes mental retardation). Second, an information processing model of mental disorder is available which can account for the phenomena of major mental disorders.

Third, what weight do we put on that vexed concept of heritability? Let me give you an example. To our shame, Australia now has the third or fourth highest incidence of obesity in the world (60%+ of males are overweight or obese) but don’t get too worried about it. We are told by the Health Dept. that the heritability of obesity is high so clearly, it isn’t just a matter of our heroic Aussies being a bit piggish. But what does heritability tell us? I say it says nothing. Heritability is a crude measure of the genetic contribution to the differences between individuals; it says nothing about the genetic causation of a condition in an individual. Let’s go back to 1945; the incidence of obesity in this country was zero, and overweight was exceedingly rare. Even when I went to school, there was never more than one overweight child per year (ie one in about 130 skinny kids; looking at the photos, fat wasn’t fat by modern standards, and the rest of us were very skinny). However, it gets worse: “At the current rate, it is predicted that 65 per cent of young Australians will be overweight or obese by 2020″ (Victorian Health Dept).

What does this say? It says that in 1945, the heritability of obesity was zero (ie no variance) but now it is said to be much higher, as in this review: “Numerous studies show that child weight status is highly genetically influenced. In a sample of 66 pairs of 3- to 17-year-old twins residing in the New York metropolitan area, the heritability of BMI and percent body fat was estimated to be 86% and 76%, respectively.” As for the heritability of major mental disorders, it is still a fact that the vast majority of people who acquire a diagnosis of schizophrenia do not have a first or second order blood relative with the diagnosis. Something else is going on.

I say the “something else” resides in the individual’s “total informational state,” meaning what he believes about himself, the world and his place in it. Trouble is, that informational state is not a matter of biology, it’s a matter of information. And information, as Norbert Wiener said 65 years ago, is not material: “The mechanical brain does not secrete thought ‘as the liver does bile,’ as the earlier materialists claimed, nor does it put it out in the form of energy, as the muscle puts out its activity. Information is information, not matter or energy. No materialism which does not admit this can survive at the present day.” (WienerN (1948, Rev. Ed. 1965). Cybernetics, or Control and Communication in the Animal and the Machine. Cambridge, MA: MIT Press. P132).

Einstein is reputed to have said that madness is doing the same thing over and over again but expecting a different result. Maybe this chap qualifies. On July 9th, Melbourne’s Herald Tribune reported on a man in Shepparton who died in a house fire at his neighbour’s house the night before: “He was staying there because his other two homes had burned down from his habit of smoking in bed. The 52-year-old’s bungalow caught fire in February, then his house on the same property burnt down on June 30. His next-door neighbour, a middle-aged woman, offered to take him in while he looked for new accommodation, but her home also caught fire around 1am today.” So now you know: going to bed is a health hazard.

Some months ago, I mentioned a psychiatrist in France who was convicted of manslaughter when her patient murdered his relative. Across the Atlantic, the Supreme Court of New York thought making people share responsibility for crimes was not a good idea. When the trustee winding up the affairs of the convicted swindler, Bernard Madoff ($65billion type swindler, they don’t muck around in Manhattan), tried to sue the big banks that had underwritten his crimes, he was told he couldn’t do it. The trustee argued that they had known, or ought to have known (ie they had the information and could work out what it meant if they could add up) that Madoff was a crook but the court found a loophole for the banks to wriggle through. Phew, that was close. Imagine being held responsible for driving the getaway car for somebody who had just robbed a bank.

A tragic suicide note by a young veteran of the Iraq was is causing some people to rethink their stance. Daniel Somers died a few months ago after years of mental pain. On level after level, he was failed by people who should not have failed, by a system that should not have failed. This commentary on his eloquent statement says more than enough.

People who start wars often don’t think about the effects their actions have on others. The mental effects of overwhelming psychological distress were not recognised for most of the twentieth century. In particular, armies and the psychiatric profession bitterly resisted the notion that ordinary men could be driven over the edge by routine military experiences. “Must have been a weak character,” was their standard response, “send him away, no pension for weak characters.”

In 1982, I saw an elderly man who has served on the Western Front during the First World War. He was a second lieutenant in the AIF at a time when subalterns had an average life span of three weeks after arriving in the trenches. That’s Average: for every one who lasted five weeks, there was one who was dead within the week. When I saw him, he was deeply ashamed of lodging a claim for mental disorder as he understood it meant weak character but his wife had recently died and he could no longer manage alone. I took the standard history and found that he met every requirement for a war-caused mental disorder, one that would now be called PTSD.

While he was there, I looked through his file which dated back to the day he enlisted in 1915. He had first applied for treatment rights in 1920 but was rejected on the basis that officers didn’t suffer mental disorders and he was clearly a malingerer. He tried again in 1930 and met the same reaction so he did nothing further until 1941, when he applied to re-enlist in the Army Reserve. He was told he was mentally ill and was not suitable but it was deemed not due to military service. He tried one more time in about 1952 before he finally got the message that real men don’t break down in war.

He was an engineering student when he enlisted, so he was made an officer and went to France with his unit, comprised of men from his own town. He knew them all, many of their fathers worked for his father, who owned a sizeable business, and he had played football with them before he went to university. His unit was second over the top in the first major action involving Australian troops on the Western Front, on July 19th, 1916, at a village called Fromelles. This was to be a feint to relieve German pressure on the British armies in the disastrous Battle of the Somme. At 9.00am that day, after a heavy barrage, he watched as the first unit scrambled over the parapet and lined up, laughing and joking as they got ready to march across No Man’s Land to the wrecked German trenches. Unfortunately, the Germans weren’t reading the same script and had survived the barrage, along with their heavy machine guns. As this twenty year old junior officer watched in horror, the first wave of troops was mown down. He had a few minutes to ponder this before it was his turn to order his friends up to their deaths. At 9.05am, he blew his whistle and his home town friends joined the 5,500 Australians killed that morning, all for no purpose whatsover. He was injured but his mental injury devastated him and he was discharged later that year.

At the age of eighty-six, he didn’t want treatment. All he wanted was somebody to write in his file that he was not a malingerer, which meant that he could go to the War Veterans’ Home. I was pleased to do that and thought nothing more of it until two years later when his daughter rang to say he had died, peacefully, and respected. “Knowing that you believed he was not a liar made all the difference,” she said. This is the point about being mentally injured by wars, it lasts such a long time.

I wonder who will treat the Iraqis and the Afghans for their PTSD?

A note on the recent survey in Bob Whitaker’s Mad in America blog. That paper is attracting some interest. Good. So far, I’ve heard nothing from our friends in NIMH. Must be an oversight on their behalf.

his has nothing to do with anything except having a good time and not doing any damage or hurting anything.

Highlighted Books and Articles

This month a colleague of mine, Christopher Struble MD, a psychiatrist in the US will be highlighting Jay Joseph’s research.

1) It has been widely acknowledged by high profile genetics proponents that the family studies (looking at distribution of mental illness in families) are confounded by environmental factors. As Ming Tsuang put it, family studies can only provide “the initial hint that a disorder might have a genetic component.”

2) The classical twin method compares reared together identical twins to reared together fraternal twins. The major flaw in these studies is the assumption that the environmental conditions of monozygotic (MZ) and dizygotic (DZ) twins are roughly the same. He has numerous references which show that MZ are treated more similarly by their parents and social environment, spend more time together, and share a closer emotional bond than DZ. He quotes Sandra Scarr, a twin method proponent, “the evidence of greater environmental similarity for MZ than DZ twins is overwhelming.” He references a 1967 schizophrenia twin study by Kringlen which showed that over 90% of MZ experience “identity confusion” during childhood (only 10% for DZ), 72% of MZ were “brought up as a unit” vs 19% of DZ, and 65% of MZ had an “extremely strong” level of closeness vs only 19% for DZ. Jay Joseph also mentions that “I’ve never seen these results discussed by any twin researcher other than Kringlen.”

3) The assumption mentioned above was classically called the “equal environmental assumption” or EEA for short. Due to the lack of evidence for it, twin researchers modified EEA to become the “equal trait-relevant environmental assumption.” Essentially, this new assumption acknowledges the original EEA as being wrong but “claims that the question is really about whether MZ experience more similar environments as they are etiologically relevant to the trait in question.” This was taken up by Bouchard, Kendler, and other leading twin researchers. This means that it needs to be proven that something in the environment that is more similar between MZ than DZ is associated with the outcome and thus the previous research was still legitimate. This then places the burden of proof on twin method critics and Bouchard himself has stated that this is a “very difficult task.”

4) Joseph mentions other factors compromising the validity of the twin method, most notably lack of adequate and consistent definition of the trait under study and non-blind diagnoses.

5) Later there was a shift to studies of twins reared apart in order to resolve some methodological difficulties which on the surface would seem to mitigate the problems listed above. However, “due to small samples, there have been no systematic reared-apart twin studies for any psychiatric condition.” To boot, one of the major studies, the Minnesota twin study by Bouchard did not allow access to their data.

6) These “reared apart” twins do not properly mitigate the similar environments problem primarily because of the selection bias inflicted by the simple fact that they needed to know about the other twin in order to respond to the study. This meant that most twins grew up in similar socioeconomic and cultural environments (often in different branches of the same family), often lived in the same home for many years AND had frequent contact. He states that “most pairs had significant contact with each other for many years.”

7) Joseph posits that “the only valid study would compare the similarity of MZ twins reared apart from birth and unknown to each other to a control group of biologically unrelated pairs of same-sex age-like strangers who are matched on all other post-natal environmental variables shared by reared-apart identical twins.”

8) “Buried within the twin research literature on schizophrenia is a finding that the pooled concordance rate for same-sex DZ twin pairs is two to three times greater than that of opposite-sex DZ pairs (11.3% vs 4.7%). Because the genetic relationship of same-sex and opposite-sex DZ twin pairs is the same, and because schizophrenia rates among males and females are roughly equal, from the genetic standpoint we should find no significant difference between these pooled rates. Therefore, these findings are consistent with non-genetic explanations of the causes of schizophrenia, since pairs who share the same degree of genetic relatedness, but who experience more similar environments and a closer emotional bond, are consistently more concordant for schizophrenia than are pairs who experience less similar environments and weaker emotional bonds.”

9) In his 2013 book chapter he provides a segment from the study which had largest proportion of the rare cases in which MZ pairs were reared apart from early life and grew up without knowing that they had a twin sibling. The first bit of this paragraph reads “In all 12 pairs there were marked intra-pair differences in that part of the personality governing immediate psychological interaction and ordinary human intercourse…..the twins behaved, on the whole, very differently…..”

Joseph provides a quote from the Nobel Prize-winning chemist Wilhelm Ostwald from the early twentieth century, “Among scientific articles there are to be found not a few wherein the logic and mathematics are faultless but which are for all that worthless, because the assumptions and hypotheses upon which the faultless logic and mathematics rest do not correspond to actuality.”

In summary, remember that concordance is the percentage of the time that when one MZ or DZ twin has the disorder the co-twin also has the disorder. The mathematics make the major assumption that the difference in concordance rates between MZ and DZ groups are strictly attributable to genetic factors. This assumption is made because MZ and DZ twins are falsely assumed to have equivalent contributions of environmental factors because they’re raised in the same household. However, the data above shows conclusively that this assumption is false and thus minimizes the amount of trust we can place in the entire body of twin research as “proof” of the genetic basis of psychiatric disorders.

Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month.

Thanks again to Alex who provided the question for this month’s newsletter.

What’s New

Lots happening this month. The long-delayed DSM-5 train finally pulled into the station but most independent commentators seemed to agree that it should have kept going. Alan Frances said that it is about time the whole concept of a diagnostic manual was taken away from the APA and handed to a responsible government agency. That’s a bit strange, there’s been a government-sponsored diagnostic manual around for a long time, 113 years to be exact. It’s called the International Classification of Diseases, issued by WHO, and we’re now up to the tenth iteration, ICD-10. In this country and in most others, all hospital admissions are coded using ICD-10, not a privately-owned manual written by drug company shills. I don’t use DSM. Some agencies insist on DSM diagnoses but they can be satisfied with two codes, one from ICD and a second from DSM. The quickest way to get rid of DSM-5 is a user’s strike.

Two things I mentioned last month, the concept of innate behavioral dispositions and “anything goes” in psychiatry. I’ll have to leave innate dispositions for another time. The problem of whether there are limits to psychiatry and where they are has always bothered me. It came up again in our little philosophy group the other week. Somebody asked: “Why are you so concerned with the idea of a science of mind? Why not dump it in the area of metaphysics and leave it at that?”

The answer is one word: Reliability. The whole question of what we should do, what is right, what works, depends on one concept: reliability. If I say to you, “Boys who jump around and talk too much in class have a biological or biochemical disease of the brain and should be put on powerful drugs for life,” how reliable is that? Is is sufficiently reliable to put them on drugs? Is it so reliable that we should be held culpable for not giving them stimulants? These aren’t trivial questions, as Martin Whitely showed (also note that we are highly over-pathologizing ADHD in the youngest children in their grades as shown by Morrow et al). ADHD diagnoses and subsequent stimulant medications are associated with giving children the diagnosis of Childhood Bipolar Disorder and they are likely to find themselves on as many as eight separate psychotropic drugs – forever. Is that life-saving, like cardiac surgery in the newborn, or is it mumbo-jumbo? Everything hinges on what we can know, what we can reasonably trust. Everybody has a different idea of what the word ‘mind’ means. They can’t all be right. This is what pushes psychiatry across the border into the area of philosophy.

I’m pleased to say that a paper will be published shortly that throws the question of the reliability of biological psychiatry right into the ring again. “Psychiatry as Ideology” will appear inEthical Human Psychology and Psychiatry later this month. It gives the results of a survey of the psychiatric literature I finished last year. I wanted to know the answer to a simple question: When people say that ordinary laboratory investigations will tell us all we need to know about mental disorder, what is their justification? In other words, how reliable is that claim? Because so many very important and influential people keep saying this, it seemed to me that there ought to be a justification somewhere. So, in a fit of madness, I decided to survey the recent psychiatric literature to find it. It started small but kept growing, until I looked at the thirteen most influential English-language psychiatric journals over a period of eleven years, to the end of 2011. There were something like 19,300 separate scientific papers, reviews, editorials, commentaries and surveys, occupying some 150,000 pages (just think of the trees). Every significant psychiatrist from all over the world was included, as well as swarms of the truly insignificant. If the justification exists, it had to be there somewhere.

Now if you’re ever feeling a bit masochistic, you try reading all that tosh. By the end of it, I was stupefied, simply scanning the contents lists of the journals, looking for something,

any thing, that would count as a justification but when you see a title like this, which has 19 authors, you know it isn’t there: “White Matter Microstructure in Individuals at Clinical High Risk of Psychosis: A Whole-Brain Diffusion Tensor Imaging Study.” That’s from Schizophrenia Bulletin. I’m quite sure the editors wouldn’t even know how to spell justification, let alone apply it to themselves. Anyway, the outcome is that nowhere, at any stage in the history of psychiatry, anywhere, has anybody in any position of responsibility, or even a complete galah, given anything that could possibly amount to a justification of the claim “mental disorder is a form of biological disease of the brain.” That’s all there is to that.

So the statement, “Yes, your son has a biological or biochemical imbalance of the brain but don’t worry, these tablets will fix him,” has no reliability. In fact, it isn’t even a scientific claim, it’s ideological, a firmly-held opinion with no empirical justification. Therefore, all the talk about the biology of mental disorder is just a case of people presenting an extremely complex issue (the nature of mental disorder) in over-simplified, biased language to give the impression that the issue has been resolved in their favor when, as a matter of established fact, it hasn’t. That is, all claims in biological psychiatry fail to meet the definition of science but, quite remarkably, they do meet the definition of propaganda. Isn’t that interesting. Also interesting was the fact that this paper was rejected by five mainstream journals without a reason. Next month, when I’ve calmed down, I’ll tell you about another rejection.

As an aside on the same topic, an article on “Suicide Disorder” in New Scientist didn’t do much for my blood pressure. They have an astounding capacity to reduce complex questions to the level where junior high school students have no doubt they’ve got a grip on them. My response is here.

Anyway, back to our little philosophy group. This week, the speaker was Dr Joyce Arnold, who gave a talk based on her PhD topic, entitled “The Kabbalah in Freudian Psychology.” The Kabbalah, as I vaguely knew, is the ancient accumulation of Jewish mythology. I wasn’t looking forward to it, thinking it would be some arcane stuff on unproveables, especially as I got over Freud about thirty eight years ago (I was cured by starting to read Fenichel. Never finished). Anyway, to my surprise, her talk was absolutely fascinating. Of course, we’re all used to Freudians saying that all of the Master’s work was Science and he discovered it himself but guess what? There’s not a word of truth in it. Seems that all of his ideas of the unconscious, myths, totems, sexuality and so on came straight from the mythology in which he was born and raised. It wasn’t science, and he didn’t discover any of it. In the original German, this is apparently quite clear (I can’t read Freud in the original, too dense) but somehow, when it was translated into English by Ernest Jones, it was sanitised and whitewashed. Jones, it seems, was a fairly virulent anti-Semite, as were the Stracheys who set up the Hogarth Press to publish Freud’s collected works. Freud, of course, was fully Germanised and didn’t want anybody to know he was Jewish. By acclamation, Joyce was ordered to keep working on her project; we only hope she can complete the project in one lifetime because it’s already grown enormously.

Somebody said something to me about “mood stabilisers” this week but I told him I never prescribe them, and they aren’t mood stabilisers anyway, just general non-specific head-whackers (the term “Mood Stabiliser” was not really used before 1995 as it was part of the marketing lingo for Depakote, see Healy The Latest Mania: Selling Bipolar Disorder. PLOS 2006 (FREE FULL TEXT)). Wow, maybe I should learn to control my tongue. He was quite put out, started spluttering about neural membrane stabilisers and so on, so I felt it necessary to ask him if he knew how these drugs got their name? He didn’t know. And what’s the connection between bits of rat nerve in a Petri dish slowing their action potentials because their voltage-gated Na+ receptors are partially blocked, and a human spending less money? Predictably, he had no answer.

The story of these drugs is enlightening. In about 1966, one of the wealthiest men in the US (and therefore in the world), the financier, Jack Dreyfus, was given a script for phenytoin (Dilantin, one of the first and most toxic of the anticonvulsant drugs). I don’t know why he got it, there’s no evidence that he was epileptic but he was an odd, difficult and abrasive character so his doctor may have been desperate. Miraculously, this transformed his life. Mr Dreyfus reckoned he was a new man (most people didn’t notice, including his wife) so he decided to sell phenytoin to the American medical profession. He set up a foundation to publicise phenytoin as an all-purpose personality restorer and eventually gave it $100mln to play with. One of their projects was to send to every American medical practitioner a copy of Dreyfus’ book,

Unfortunately for his pile of loot, it stayed overlooked, partly because the patent was about to expire and the manufacturers weren’t much interested, but not least because phenytoin is unpleasant and very toxic. As a highly effective anti-folate agent, there is hardly an enzymic system in the body that it doesn’t mess with. Neurologically, it interferes with cognitive and motor function to make people look and feel drunk. It is widely rumored that Dreyfus fed the drug to his friend, Richard Nixon, as he thought it would help his depression. It didn’t, of course.

Anyway, by 1974, when I started psychiatry, people were trying carbamazepine in place of phenytoin. About 1968, two Japanese neurologists had found it was effective in calming very aggressive patients (there has always been this vague notion floating around biological circles that aggression is a form of pathological brain discharge), so it wasn’t long before it was being given to odd, difficult and abrasive patients in psychiatry (like Dreyfus but without the money). From there, it was a small jump to trying it on psychotic patients. It wasn’t a powerful sedative but it seemed to iron out the little ups and downs seen in some people with manic-depressive psychosis, so in no time, it was being sold as a remarkable new advance, to help people who couldn’t tolerate lithium (most of them). Nowadays, there is a major industry diagnosing people with the bipolar syndrome and putting them on huge doses of drugs for life. The drugs have been given a new name (mood stabilisers; again see Healy), just as phenothiazines etc. were renamed “antipsychotics” to increase their market.

Give out research grants to keen young psychiatrists who need to climb the academic slippery pole. Remember, anecdotally I’ve heard NIH grants generally pay the institution 50-70% off the top (50% Temple University, >70% University of Pennsylvania). Since big-time researchers do meager to no clinical work, no grants = no job.

Subsidise conferences, buy lots of adverts in psychiatric journals to the point where the editors are scared to upset the advertisers, etc.

Watch your sales grow and laugh all the way to the bank.

Nifty formula, isn’t it. It never fails.

As I said, I never prescribe these drugs. It is no doubt a coincidence that my patients never develop “rapid cycling bipolar disorder.”

So much for the good news. The bad news came from our dear friends at the American Psychiatric Association jamboree in May. Somebody from South Carolina feels the need for a new psychiatric subspecialty, to be called “Interventionist Psychiatry.” Just as other medical specialties have branched out into what they call “interventionist medicine,” so should psychiatry, they feel. With advances in medical technology, specialties like radiology, gastroenterology and neurology have broadened their scope and now perform “interventionist” procedures. This means sticking needles and tubes into people to find out what is happening inside (gastroscopy, colonscopy, hysteroscopy etc) or inserting stents under radiographic control, and so on. Biological psychiatrists, ever anxious to keep up with the Dr Caseys, think we should be allowed to, too. Needles in the brain, that’s what you need, my good man. (I can’t give a link, it’s subscription only but the article was in Medscape,

A New Psychiatric Subspecialty?May 30, 2013).

The authors listed all sorts of ways of spreading joy (not least because procedures make heaps more money than just sitting there listening to people). Their list included:

-ECT (of course). By the way, after 36yrs of working alone in the most difficult parts of this (admittedly difficult) country, I have to point out that I never use ECT. Never. In both psychiatric hospitals where I was chief psychiatrist, ECT stopped for the duration of my stay, and bed occupancy rates went down. As soon as I left, the ECT was resumed and occupancy rates went back to normal. Nursing unions were greatly relieved as it meant there was no further risk of closing wards. Now that’s a shocking (!) thought, isn’t it, nurses as advocates for ECT. We won’t go down that path today.

-Vagus nerve stimulation (VNS). As its name sounds, makes your stomach gurgle. However, the authors added glumly: “Unfortunately, VNS was FDA approved prior to any Class 1 evidence of efficacy; thus, insurance companies have been reluctant to reimburse for the implant.” Well, what a bunch of killjoys the insurance companies turned into. They want evidence? What next? But how does the FDA approve procedures without evidence? Next question, please.

-Deep brain stimulation (DBS), that’s what’s next. This involves sticking needles deep into the brain and lightly charring a few nuisance spots. However, they tossed in this aside: “There has also been an explosion in psychiatric side effects of DBS used for neurologic conditions like Parkinson disease.” This is not a brilliant start. When DBS is used for Parkinson’s Disease, it regularly drives the patients mad. Perhaps this is why they thought it should be used by psychiatrists. But don’t worry: “The interventional psychiatrist should be adequately trained to troubleshoot these issues.” First we drive you mad then we treat you.

-Finally, Transcranial direct-current stimulation (TDCS). This means wiring a person to get a weak DC current across his head. The good news is that 1mAmp won’t kill you, unless you get addled and walk under a bus. Just for reassurance, they noted: “A recent study from Brazil demonstrated that when combined with sertraline, there is a synergistic effect in treating depression.” Nobody would know. You could walk around with your patches on and everybody would think you’re listening to a samba on your iPod but you’re secretly getting your jollies, that’s if you can put up with having no sex life because of the sertraline. But don’t you love the next bit? “There are limited data currently, but it seems to have great promise and low cost.” Of course there are limited data available, that’s why they can talk breathlessly about it and suck the grants committees in. As soon as the hard data start to come in, it’ll be found to be nothing more than placebo. They always are. You’d think they’d learn, but that’s one thing about biological psychiatrists, they never get depressed over no results. Now if we could just distil that from them and market it, we’re made. A bit like Groucho Marx: “In business, sincerity is everything. As soon as you can fake that, you’ve got it made.”

Not to be outdone, Psychiatric Times jumped on the bandwagon with an article entitled “Deep Brain Stimulation: Evidence-Based Science or Wishful Thinking?” It was just a rehash of the usual gee-whiz nonsense, the only improvement being that the reporter had the grace to admit she didn’t know how to tie her shoelaces. We knew that, but who would put it in a newspaper?

As a corrective to their Brave New World, if you haven’t seen the story of Walter Freeman, “The Lobotomist,” a documentary on PBS, you should. Ultra-scary. Be warned: Do not watch before bedtime. Talking of billionaires, I see the exquisitely detestable HL Hunt, role model for Dallas and inventor of ultra-conservative (read: fascist) radio and TV disinformation shows (based to some extent on the enviable success of a certain Herr Joseph Goebbels in Germany), had some fifteen children by three wives (all at once). His eldest son, who imbibed a little too deeply of his father’s virulent paranoid bile, had the misfortune to became a patient of the good Dr Freeman. Hassie, as he was known, declined to wear clothes ever thereafter but wrapped himself in a sheet, telling people he had to haunt the lake on their estate as the family ghost. Sad but true.

Had a quick trip to Sydney this week to appear on a panel for the Rural Health Education Foundation, which tries to rectify some of the imbalances in opportunities for people who work “out there.” It turned out to be a lot of work but everybody seemed to think that, for a bunch of complete amateurs, the five panelists did very well, including Jodey, first time on TV and about 38wks pregnant. We wish her well. I managed to get in my line about antidepressants increasing the risks of suicidal behavior in the young.

Highlighted Books and Articles

The month the Journal of Clinical Psychiatry will obtain the dubious distinction as my first negative highlight. When writing the above section I wanted a link for point 6 showing a pile of drug ads. I knew J Clinc Psych was the go-to place as it’s usually littered with a density of advertisements which rivals an accidental click to the most obnoxious of spam webpages (usually, the lions share of the ads are for the pharmaceutical du jour). Quizzically, the site had some conspicuous ads to “Psychlopedia,” which it turns out is a CME company owned by the publishers. Clicking on the ads leads to a CME interface within the framework of the journal’s website and boasts “Physicians Postgraduate Press Inc, publishers of the Journal of Clinical Psychiatry.” A quick scan through ALL the CME courses available (including the archive) revealed a whopping 40/47 overtly claimed drug company grants. Three of the four current “courses” for “ADHD” were sponsored by Shire Pharmaceuticals, the makers of the famously addictive, lucrative and diverted to the aftermarket Adderall (mixed amphetamine salts). The other was sponsored by Eli Lilly, the makers of atomoxetine (Strattera), a drug approved by the FDA for ADHD. Of the three current courses for “bipolar” one was by Sunovian, the makers of the new Latuda (lurasidone), one for Bristol-Myers Squibb, the makers of Abilify (aripiprazole; which has just come out with a long-acting formulation), and one for Eli Lilly, the makers of the new Zyprexa (olanzapine) long-acting injection Relprevv (which recently 2 patients died from days after receiving an appropriate dose with very high levels of drug in their system). Interestingly, 2/6 of the courses from the banner advertisements led to allegedly independent CME courses (remember, there are only 7 independent courses total, 2 of which are used in 6 ads). This could certainly skew one’s initial perspective on the ratio of courses with drug company involvement in the Psychlopedia CME program, especially when one is new to the site and making that fateful decision whether to take the time and setup an account (to be followed by a barrage of intrusive emails).

I’m sure some aspiring-to-be-black-boxed medical student or resident could have a field day making connections between the content of this journal and its corporate partners. Too bad it’ll be published in a journal nobody reads, unlike the Journal of Clinical Psychiatry which is “gifted” without signing up and without a subscription to the mailboxes of psychiatric residents.

What’s New

A series of questions from newsletter reader, Jack Fenwick, has focused on some critical issues facing this model of mind, and also some very important social issues facing humanity. I’ll quote his email (with one or two minor changes):

“”Whilst you’ve now convinced me that mental disorder can be generated in the psychological realm and it is basically distorted personality rules that are driving disordered thought and behavior, does it not raise the question of how those rules came to be codified in the first place? What is the developmental process that creates them, is this not where biology (in terms of epigenetic effects), might come into play?

Children can potentially be exposed to the full spectrum of psycho-social environmental possibilities – from the nightmarish to the pristine – during their development. How is some can have a horrible experience during their development years (arguably where most of the personality rules are coded) but turn out balanced and functioning in the end?; likewise, why do some come from stable backgrounds, both at home and in their wider social settings, but go on to become mentally disordered? Is this where biology might have a causative role in the development of a disordered mind?”I’ve only done a cursory bit of reading into the genetics of personality development (says Jack). Though I suppose that’s a solecism, because from what I did read, it seems genetics doesn’t have much to say at all about personality. They certainly couldn’t find any genes to correlate for certain personality traits. Still, I think we are left with the question, what mechanism causes some to become disordered despite being exposed to the same or similar psycho-social milieu in developmental years?”

I’ll start with the points as he lists them: “… mental disorder can be generated in the psychological realm…”

If, by virtue of its very high-powered, multi-modal, multi-channel switching capacity, the brain functions as an information processor (which it certainly does), then there is no reason to believe that primary errors cannot arise in its information processing without any prior errors in its physical structure as a switching machine. Anybody who says that primary psychological disorders cannot arise due to errors in the brain’s algorithms or in its data set clearly doesn’t know the first thing about information processors.

I am not saying that, as a matter of necessity, all or most mental disorder is a primary psychological disturbance, even though it certainly seems to be true as a matter of daily experience. All I have to do here is show that the claim by biological psychiatrists, that all mental disorder is necessarily due to a “chemical imbalance of the brain” is utter hogwash, and that has been done. So when the director of the US NIMH, Dr Thomas Insel, says that their new research “…framework conceptualizes mental illnesses as brain disorders…” he is talking rubbish. There is absolutely no proof in the scientific or philosophical literature that there is any basis to this belief. Anyway, it flies in the face of common sense to say that information can’t be corrupted for some reason or another. Just crazy.

“…basically distorted personality rules that are driving disordered thought and behavior…” A large part of the work on the biocognitive model is directed at the notion of normal thought and behavior, because this is logically prior to abnormal or disturbed thoughts, experiences and behaviors. I think the concept of personality is pretty straightforward, it is the set of unique rules each of us has that guide our daily activities in such a way as to distinguish us from our neighbors. This draws a line between personality and culture, which is the set of rules that we have in common with our neighbors. A lot of mental disorder does arise from “distorted personality rules” but a lot also arises from people being submitted to massive or prolonged psychological distress. A woman trapped in an unhappy marriage may have a perfectly normal personality but can still develop a severe depressive state. A normal soldier can develop a disabling state of agitation as a result of overwhelming experiences in the field. A couple I saw this week are very distressed to the point of struggling to manage just because their son is in a mental hospital and seems to be getting worse, not better.

Of course, abnormal personality factors can make it more difficult for a person to cope with routine psychological pressures (“Ohmigod, hurry, we’re going to miss the train!” “Calm down, there’s another one due in five minutes.”) At the same time, some people with even moderate personality disturbance can’t cope with normal life but thrive in adversity: there are some people who actually like drama! A lot of the people who built the British Empire had quite gross personality disorders but nobody minded as long as they stayed overseas. The real job is to sort the personality factors from the reactive. That’s when the work gets interesting.

“…raise the question of how those rules came to be codified in the first place?

“Ah, now you’re talking. I have always believed we are Homo nomotheticus, the rule-abider, even before we can be Homo sapiens, the knower. A rule is simply a regularity. We have untold rules in our systems, our entire biology is based on regularities, but the rules of our informational states are different. In short, if we don’t have rules, we’re nothing. We can’t even speak without rules to say what each sound signifies. Thus, Chomsky’s concept of a rule-based generative grammar is a subset of the larger biocognitive model of mind, which says that rules are the basis of everything we do. So how do we acquire rules? I think it is true to say that we are rule-gatherers extraordinaire, from the moment we can lift our heads, we are constantly scanning the environment to extract generalisations that we use to survive. We mine our surroundings for rules that allow us to predict the next few minutes, and we never stop. We need to know what is safe to eat and drink, where we can safely walk, what we can touch and what has to be avoided, who is likely to be dangerous and so on. If we can’t find generalisations that allow us to make sense of the world, we die.

So now we start to see how the rules cluster. There are the normal rules that a reasonably sensible chimp could work out, like what is safe to swing from, what is safe to eat and which animals not to annoy. These are so basic to human life that we hardly give them the title of “rules,” we just call them common sense. Next, there are the rules of language which, as Chomsky likes to point out, we extract from the social environment very early in life, based on very limited experience of language. I’ve talked about this in Chap. 8 of my second book,Humanizing Psychiatry: the biocognitive model. Third, we have the rules of culture, including subcultures, and last the rules of personality. They form a sort of hierarchy but this is not fixed in concrete (or in biochemistry). What is the nature of a rule? It is an instruction of what to do in certain circumstances, essentially information coded in memory, but it doesn’t have to be explicit memory. It’s highly likely that, of all the tens of thousands of rules we have, a large part of them are learned implicitly. Indeed, the rules of language are being learned before we can form a sentence.

One topic that I find very interesting is the question of innate behavioral dispositions or, in social terms, human nature. That is, what are the inherent dispositions to act in certain ways that are part of our biological heritage? There are dispositions, that much cannot be denied: we are social animals; we are highly competitive and quickly form dominance hierarchies; we are territorial and xenophobic; we have a strong sense of curiosity or exploration drive; we are both selfish and altruistic, and we don’t tolerate uncertainty. We need to know what lies over the next hill so we will go and have a look (males will, females are usually content with this valley) but if we can’t find out, we will invent a convincing story to fill the gap. I think a lot of these are hormonally driven, just as they are in the other higher apes, so we are probably better talking about a “higher primate nature” rather than human nature, because it’s practically the same thing. More on these questions next month.

Here is a great link to the Nine Circles of Scientific Hell. I’d say they would be pretty crowded……and here’s a good example of people who should populate the lowest level of Scientific Hell forever, with no remissions:

Here in Brisbane, we have a small group of psychiatrists called the Philosophy Interest Group (PIG for short) which meets to try to foster some sense of awareness of the broader issues in psychiatry. At a recent meeting, conversation turned to Heidegger and various other luminaries of the continental school of philosophy. I said they could not be used in psychiatry because their concepts are so poorly defined that anybody can read whatever they like into them, that phenomenological philosophy cannot form the basis of a single model of mind and thence a model of mental disorder or of treatment. In particular, they do not define limits to psychiatry and they thus licence “anything goes,” which opens the door to all sorts of fringe, loopy and/or dangerous (but often highly profitable) “therapies.”

Well, did that bring the demons of hell down on my neck! “Psychiatry doesn’t need a single model of mental disorder, we can use what we like for different cases. We can use a bit of this model and a bit of that to build a treatment program that is tailored for the individual rather than the ‘one size fits all’ approach of orthodox psychiatry.” Very clearly, the other members were highly satisfied with their (unanimous) rejection of my pedantic view of theories in psychiatry. One of them suggested we need to be creative in our concept of mental disorder, as there are multiple universes we can access to understand the patient, including the ordinary physical universe, the emotional universe and the spiritual. These coincide in the individual person but also different people’s emotional universes intersect so it is possible to have direct access to another person’s emotional state (or something like that, the bit about intersecting universes was a little garbled).

OK, saith I, but tell me how you would set limits to this. I knew a psychiatrist once who said that all mental disorder is due to lack of self-esteem caused by lack of love in infancy and the way to treat it was to give the patients some love now to make up for it. Trouble is, his idea of love was carnal and he eventually went to prison for a long time, but not before he had damaged a lot of people. Given that we can essentially make up a model to suit anybody, and no two psychiatrists are required to agree on what is wrong with the patient or how to treat him/her, why should anybody take psychiatry seriously, certainly to the point of paying them to do something that nobody else can do? Didn’t get an answer to this, meeting broke up soon after, leaving me hugely pissed off. In 1996, I wrote a short paper called The Myth of Eclecticism in Psychiatrywhich should have finished this sort of stuff off. Seems that if you chop one head off the beast, another pops up.

What, it seems, are the choices in psychiatry? A dehumanizing, reductionist approach that sees humans as nothing more than collections of brain enzymes to be drugged, cut or electrified, versus some weirdo, fun-filled, touchy-feely, new age fantasy? We don’t need to go into the risks of treating people as pithed toads, you can see that every day at work. On the other side of the fence, if we let unprovable notions in, then there is no limit, in no time, people are going to be invoking gods to justify what they do to patients, or importing morality into mental disorder and so on. Or is there a third path, a formal, articulated theory of human mental life and what can go wrong with it? I believe there is a formal theory of mind and its discontents and it is our job to find it, not to use our prejudices to do horrible things to people who can’t protect themselves.

So over the next few editions of this newsletter, I want to explore the formal ideas behind the work that has led to the biocognitive model of mind. The basic principles are as follow:

First principle: The human mind is a real thing, able to act in the real, tangible universe, which we can understand.

Two: There is a rational, natural account of human mind. This means that we don’t have to invoke the supernatural to explain the mind.

Three: There is only one correct theory of mind, and…

Four: It follows, then, that there are only certain ways that minds can malfunction, so there is only one correct theory of mental disorder. Biological psychiatry is not it.

We will talk more of these limits over the next few weeks. Any contributions or ideas, objections etc. are welcome.

A fascinating look at recent history (if fifty years is still recent), of how one determined woman blocked drug companies releasing thalidomide in the US in the early 60s, thereby preventing an epidemic of phocomelia. What a pity that lesson isn’t more widely taught.

Psychologists love to name things, and here’s one I hadn’t come across: The Coolidge Effect.

In experiments with rats it has been observed that after vigorous copulation with a new partner, male rats soon completely ignore this partner, but when a new female is introduced, they immediately are revitalized – at least sufficiently to become sexually active once more. This can be repeated again and again until the male rat is completely exhausted. This unexpected finding has been observed in all tested male animals, but also in females. Female rodents for instance flirt more and present themselves more attractively when observed by new males than in the presence of males with whom they had already had sex.

This phenomenon has been called the “Coolidge Effect” after the American president. On a visit to a farm, Mrs Coolidge had been shown a rooster who could copulate with his hens all day long, day after day. She was quite taken with the idea and asked the farmer to let the president know about this. After hearing it, the famously reticent Pres. Coolidge thought for a moment and asked: “Does he do that with the same hen?”

“No, sir” replied the farmer.

“Please tell that to Mrs. Coolidge,” said the president as he strolled away.

I see a media flurry over the recent announcement that the US National Institute of Mental Health (NIMH) has decided it’s not going along with DSM-5 but will focus its efforts on its own program, the Research Domain Criteria (RDoC). Dr Thomas Insel, Director of NIMH, has finally agreed that what the DSM project lacks is not reliability, but validity. That is, if we have a hundred psychiatrists and show them a patient and they all agree, Yes, he’s schizophrenic for sure, then we have 100% reliability (every similar case will reliably be placed in the same category) but are they right? That is, should he actually be placed in that category in the first place. “Patients deserve better,” he said, and pointed to the RDoC as an example of what he thought was better, i.e. a system of diagnosis based on biomarkers. But don’t be in a hurry, he warned, it will be at least a decade before they see any results (and $15bln at current spend rates).

He’s right, patients certainly do deserve better. Oddly enough, quite a few people have been saying just that for quite a few years but it’s nice to know the NIMH is finally starting to catch up. The question of validity is critical. Consider another example, educating Aboriginal children in the north of Western Australia many years ago. I remember a teacher telling me they were hopeless, it was a waste of time talking to them as they didn’t have the intellectual firepower to do anything more than sit in the dirt scratching their scabies. Another teacher agreed firmly with him, so here we have a case of 100% reliability. They looked at the same cases and came to the same conclusion. All very good, but was their diagnosis valid? In fact, it wasn’t. All the children had chronic otitis media, so they weren’t stupid, not stupid, just struggling along with about 10% hearing. Same goes for psychiatry. We may be able to train psychiatrists to be pretty reliable on matters such as ADHD but does that prove anything? No, nothing at all, it only shows that people can be trained to agree, just as once they were trained to agree that this sign or that meant witchcraft. So validity is the sticking point but, with my usual tastelessness, I pointed out some years ago that RDoC can’t provide validity (Cells, circuits and syndromes. A critique of the NIMH RDoC project. Ethical Human Psychology and Psychiatry 2011, 13: 229-236; an expanded and less polite version is Chap. 9 in Mind-Body Problem Explained, published 2012).

The American Psychiatric Association isn’t taking this barrage from NIMH lying down. Dr David Kupfer, Chairman of the DSM-5 committee, retorted that his DSM-5 “represents the strongest system currently available” for classifying psychiatric disorders. “We’ve been telling patients for several decades that we are waiting for biomarkers (i.e. from bioresearchers). We’re still waiting,” he said tartly. Oh dear, there’s dissension in the camp. Interesting, because for decades, psychiatrists have been eating out on the promise of biomarkers and cures for their putative “chemical imbalances.” Now it looks as though we may have a few more decades to wait. One wonders how long it will be before it dawns on somebody in NIMH or any of the other agencies that perhaps there aren’t any? That, by definition, psychological matters don’t have biomarkers?

To set the record straight, a rather panicky press release by Dr Jeffrey Lieberman, dated May 18th 2013, pointedly not sanctioned by the APA, said both he and his good friend, Tom Insel, didn’t mean anything like that and it was all a silly misunderstanding. It ended with the comment: “Psychiatrists would like nothing more than to see laboratory tests and imaging — routine in diagnosing other diseases — incorporated into the DSM and clinical practice.” Well, that depends on which psychiatrists you’ve been talking to. Those with shares in drug companies and tech firms might but those of us who have a formal model of mental disorder don’t need it.

Enough talk. This month, I’ve been too busy revising basic cell biology and neuroscience to read anything else. If anybody has read an interesting book, feel free to send in a review. Also, my little handbook on philosophy for medical students is available on Amazon’s Kindle for the princely sum of $4.95, that works out at about 2c per definition. Cheap!

It is one of the fundamental beliefs of modern psychiatry that the mentally-disturbed must have drugs to prevent their disorders deteriorating. Drugs are now given in the very long term, generally meaning for life, even though almost none of the drugs has ever been tested in anything like the longer term: most drug trials last only a few weeks or maybe a couple of months. A problem soon arises because the side-effects take a while to appear and become troublesome. For example, many modern psychiatric drugs cause massive weight gain but this is normally not seen under about four months or more. So it is only when people are home and trying to get back to normal life that they realise, “Hey, this stuff isn’t good for my figure/ my sex life/ my ability to think or learn/ my skin/ getting a job/ staying awake to talk to people, etc.” They may raise the matter at one of their monthly appointments at the mental health service only to be told, “Don’t worry, that’s not a problem, just keep taking your drugs, you’ve got a chemical imbalance of the brain.”

As a result, a lot of them stop taking the drugs, which throws the service into a panic because they are firmly convinced that to stop taking the drugs is to court disaster – and, coincidentally, takes away their reason for existing. This is despite the clear and accumulating evidence that psychiatric drugs aren’t as effective and are much more toxic than people claim, and are probably contributing to the “epidemic” of mental disorders (eg David Healy’s Pharmageddon 2012). In orthodox psychiatric circles, it is firmly believed that if people stop their drugs, they will end up in hospital again. Non-compliance, it is believed, causes the “revolving door” syndrome, where people go in and out of hospital with monotonous regularity.

For some reason, going to hospital is seen as A Bad Thing but that’s another matter. For the administrators, if people come in and out because they have stopped their drugs, then the obvious solution is – stop them from stopping their drugs. Hence community treatment orders. A CTO is a form of civil custody, where a person living at home can be ordered to accept whatever treatment the hospital deems necessary. There are usually lots of other restrictions so the final order is often much more restrictive than a parole order imposed on somebody released from prison after a major crime. However, the larger society is prepared to put up with some of its members suffering severe losses of civil rights if it is For Their Benefit, and the way to measure benefit is to look at the number of admissions to hospital.

CTOs are in use in many countries of the world, including Australasia, the UK, many states of the US and provinces of Canada, and some European countries. It is of interest that they are seen as terribly modern, but we had exactly the same system in Western Australia in the 1960s and 70s, when it was known as After Care. Anybody who had been admitted as an involuntary patient could either be discharged Outright, meaning he was completely free of the Mental Health Act, or to After Care, a sort of legal half-way house in which he was still technically a patient even though he was living independently. He got out earlier and had to take his drugs and try to behave himself but the trade-off was that, if he did anything wrong, he more or less had a ready-made mental defence. So After Care status was kept under strict control, it wasn’t handed out for fun. It had no effect, of course, the admission rate in WA was exactly the same as in states that didn’t have it but it probably cut down on administrative time and paper work so it wasn’t all bad. All it took was answering a few questions about the patient and one signature, and off he went.

What once involved a quick talk with the patient is now a frankly adversarial matter. Getting a CTO is A Big Deal, with a cast of thousands. The patient must appear before a mental health tribunal (three very highly paid people), usually with a lawyer of his own from legal aid and one or two nurses as escorts. On the other side, there will be a psychiatrist, usually a registrar (resident in US), a medical officer or intern, a social worker, quite often a psychologist, a clerk and one or more people from security. The hearing is quasi-judicial. It will normally last an hour or more and may be adjourned to get more reports or ask witnesses to attend, so the patient has to stay in hospital. However, despite the forbidding setting, they are really quite chummy affairs as everybody knows in advance what the outcome will be: whatever the hospital asks for will be granted, if not more. These things cost a heap of money, something like $2000 an hour while the circus is in session. This is all put down to Helping The Mentally-Ill, when it doesn’t help them one bit. It helps all the people getting paid to hang around while somebody dithers over the meaning of a word in the Act.

Conditions can be onerous. One man I have seen was placed on an order eight years ago after he accepted bad advice from a lawyer and pleaded not guilty by reason of insanity to a matter that would have involved a six month bond, or perhaps a short period of probation. Instead, he got eight years of torture, with more to come. He must stay in his own home, so he cannot stay overnight at his mother’s place about two hours away. He cannot buy or sell any property or anything of value (such as buy a car). He is not allowed to drink or go to a place where alcohol is served. He cannot leave the town nor move interstate (as he wants to do). He has to keep his house to a standard the nurses think reasonable. Nurses can come into his house at any time of day and order him to hospital for no stated reason. He must accept any medication prescribed by the psychiatrist in any form for any psychiatric reason. All this is in place for a man in whom I could not find a significant psychiatric symptom (he hasn’t had any for about 7.5yrs) and for whom the hospital could not provide a diagnosis. When asked why he was considered a danger, there was no evidence at all. In fact, the act does not require any evidence, only the “perception.” Oh, and it costs a lot of money to keep him trussed up legally.

So it is of interest that somebody has at last looked at whether these orders do what they are supposed to do, keep people out of hospital. A carefully planned study by a psychiatrist in the UK, Tom Burns, has used the standard of a randomised clinical trial to see whether CTOs are any better than no orders. His team assigned nearly 350 patients to two groups, one placed on an order and one without, and followed them to see whether they were readmitted. The groups were practically identical on all social and psychiatric parameters. So was the outcome. Being on a CTO made absolutely no difference to whether the patient was readmitted during the study period:

“Despite a more than three-fold increase in time under initial supervised community care, the rate of readmission to hospital was not decreased by CTOs. Neither was the time to readmission decreased nor was there any significant difference in the number or duration of hospital admissions. We also recorded no differences in clinical or social outcomes.”

Two previous but smaller studies from the US, from 1999 and 2002, reached the same conclusion:

“The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms… International experience indicates that clinicians rapidly form strong opinions for or against CTOs and clinical equipoise is soon lost.” (I like that expression, it means ‘their prejudices beat balanced judgement’).

There is another aspect to consider, and that is the way the movement to legislate CTOs has spread around the world in the absence of anything that approximates supportive evidence. If we look at the drama surrounding, say, childhood immunisation, cigarettes, compulsory testing for HIV or mammograms, it becomes even more remarkable that people were able to convince legislators to impose major restrictions on civil rights for an essentially defenceless group. We would like to think that if there is no advantage or benefit in CTOs, they will be dropped but I’ll lay any money that won’t happen: there are far too many people making a handsome living out of CTOs for anybody to dare talk about amending mental health acts to get rid of this useless bit of bondage.

“If a nation murdered and sterilized an estimated 73 percent to 100 percent of its diagnosed schizophrenics, yet a generation later that nation had a higher rate of incidence of new cases of schizophrenia than did surrounding nations, shouldn’t we have questions about the claim by the mental health establishment that schizophrenia is highly heritable?” (Truth-Out, Jan 18th 2013 ).

Drawing on figures from Germany, published in an authoritative report in Schizophrenia Bulletin in 2010, Levine quoted a psychiatrist, Heinz Häfner at the University of Heidelberg:

“Häfner reported that in Mannheim, Germany for each year from 1974 to 1980, new incidents of schizophrenia ranged from 48 to 67 per 100,000, averaging 59 per 100,000. Häfner compared the rate of new incidence of schizophrenia in Mannheim with 11 studies in the Netherlands, Italy, Denmark, Norway, Iceland, the United Kingdom, the United States and Australia. The non-German locations averaged 24 per 100,000, less than half the incidence rate for Mannheim. Another study done in Bavaria, Germany in 1974-1975, reported an annual incidence rate of 48 per 100,000, double the incidence of non-German locations. Today, the World Health Organization reports the prevalence of schizophrenia in Germany is virtually the same as it is for other European and North American nations.”

Oh dear. This puts quite a twist on the oft-repeated argument that schizophrenia is a “genetically-determined chemical imbalance of the brain” or, in the words of the current director of NIMH, a “disorder of neuronal circuits,” whatever that means (I have argued that it actually means nothing; that paper will appear in

Ethical Human Psychology and Psychiatry later this month). If the gene pool for a genetic disorder is wiped out but the disorder just keeps popping up, surely that says something? Levine says we need to question the concept of heritability in this and other mental disorders:

“When we begin to question, we discover that (1) scientifically flawed research has been used to promote ideas around mental illness and its heritability, and (2) instead of focusing on nature vs. nurture causes of mental illness, it’s time to consider whether certain phenomena are really symptoms of pathology, or instead are inextricable aspects of our humanity.”

That is music to my ears. I’ve been saying for decades that the concept of inherited mental disorders is far more complicated than orthodox psychiatry makes it out to be. The most reasonable explanation is that the disease of schizophrenia is promoted by the interaction of a large number of genes (ie polymorphic), each of which contributes a very small part of the variance but none of which could cause the condition alone. These are normally distributed in the population and may even be beneficial; unless the person gets a multitude of doses (or several very deleterious ones), he won’t manifest the disease but can pass on the tendency (ie this is a process of summation, think of the broad concept we define as “intelligence” and the many different pathways to “intelligence”). This line of thought fits perfectly with the best genetic evidence we have currently, as can be seen at http://www.szgene.org, a website which Ioannidis (his bibliography) helped develop to create an evolving meta-analytical database of schizophrenia genetics research. A quick look through this site will reveal how limited the contributions are for each gene. I was unable to find any that had an odds ratio (OR) of less than 0.70 or above 1.3! For those not versed in statistics this approximates 30% higher rates of protection or risk (ie not that much compared to associations such as insomnia increasing the subsequent risk of depression by many times over, likely somewhere near 500%). This line of thought dramatically changes the way we conceptualize the genesis of schizophrenia. Instead of just being an on or off phenomenon we now have a continuum, a concept that runs contrary to the yes or no categorical methodology of the DSM. Conceptualizing schizophrenia as a blending of risk provides a much stronger footing for mental and environmental contributions. Notice that above I said promoted, not caused. With this line of thought a person can have one of many substrates for schizophrenia but have not been in a position psychologically to “throw them over the edge.” Obviously, the presence of a continuum means there are varying degrees of severity and therefore the homogenized approach of simply checking boxes and giving medications will not do. This leads to a form of treatment that is tailored to the patient with a limited use of neuroleptics and an absolute need for therapy. When utilized, neuroleptics should facilitate therapy but be minimized or even discontinued once symptom control is established (this statement is not out of line: see the 15 yr follow up of Soteria by Harrow). An example of this method with outstanding outcomes is employed in western Lapland, Finland, and can be found at Seikkula et al 2006. An excellent overview with interviews of Dr. Seikkula is outlined in Robert Whitaker’s Anatomy of an Epidemicpages 336 to 344. For those who still believe the sweeping claims the geneticists are making I would highly recommend reading the critical work of Jay Joseph. Their methodology is not as solid as they’d like you to think.

Highlighted Books and Articles

Talking of books, one of the most renowned of American philosophers, Thomas Nagel, has recently published a book with the provocative title, Mind and Cosmos: Why the materialist neo-Darwinian conception of nature is almost certainly false (2012, New York: Oxford University Press). Nagel found fame (or notoriety) in 1974 with a paper called “What is it Like to be a Bat?” This is an extremely widely quoted paper although I must admit I’m not quite sure why, as most people quote it only to ignore it. It’s actually a subtle defence of mind-body dualism by way of putting almost insuperable difficulties in the way of physicalists or reductionists (as biological psychiatry is), but that has done nothing to slow the rush to biology, even among philosophers (such as Dennett, Searle, Thagard and Jackson).

But anyway, back to his book. It has attracted enormous attention, last time I looked, there were over 35 reviews listed on Google, mostly weakly approving or overtly disapproving (I wish I could get 35 reviews, good or bad, for a book of mine). I find this book is a bit of a problem. It’s written in a very personal style (meaning, not very clear) and comes across more as the lament of an old man (75yrs) who feels that his very reasonable message has not been given the attention it deserves. I don’t like most evolutionary theorising in psychology and human affairs, yet even I can’t find much sympathy for his major complaint against Darwinian theory, that it doesn’t seem plausible. He won’t do much to prevent the very rowdy people on the other side of the fence, Dawkins, Dennett and company, from dominating the airwaves with their over-simplified and essentially ideological evolutionary ranting. Why? Because it’s easy to turn your opinions into a Just So story using a dumbed-down version of evolution, much harder to present a subtle and carefully argued case against it.

So will Nagel’s swansong win many converts to mind-body dualism, or even force people to pause and question the concept of biological reductionism? Sadly, no, it won’t. The main reason takes a while to emerge: After a lifetime of philosophising, Thomas Nagel doesn’t have a theory of mind. All he has is the humanist intuition that mind is something more than the brain and he can mostly find holes in the main reductionist arguments but that’s where the matter ends. That’s a pity. We need more people prepared to stand up against the biological onslaught because, until there’s a formal theory of mind, there won’t be a formal theory of mental disorder.

If anybody wants to contribute a book review, or has something they want to publicise, feel free to send details.

Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month!

“Sometimes I wonder whether the world is being run by smart people who are putting us on, or by imbeciles who really mean it.” (Mark Twain).

The week got off to a good start when a paper on causes of mental disorder I had been hawking around since July last year was finally accepted. It was rejected in the usual week or two by two prestigious journals so I went down the food chain to a second tier journal. They promised a response in one week. Just over five months and several enquiries later, they rejected it with what I think would be the worst review I’ve ever seen. One of the reviewer’s complaints was that I hadn’t mentioned the biopsychosocial model as a valid explanation of mental disorder. I didn’t, because it isn’t: In 1998, I showed that it didn’t exist. It was never written and the whole “biopsychosocial industry” is now a gigantic fraud. Well, it would be apart from Twain’s pithy observation, above. So the question arises: how dumb does a psychiatrist have to be to believe that something exists when there is proof positive that it was never written? This is a grave worry, these are people have enormous power over people’s lives yet the level of explanation they use is about on the level of pixies and wood nymphs. There were about half a dozen more bloopers of a similar order of stupidity in that review so I sent the paper to a journal which still retains some critical reviewers on its list. In due course, back it came: “This is a very important paper…” Hey, glad to hear that, I think so too, that’s why I wrote it.

The paper looks at the reliability of the claim that mental disorder has a biological basis. There is no doubt that this is a major claim about the nature of something that affects about 25% of the population directly, and even more people indirectly. In the US alone, the mental health industry alone has a $100billion a year turnover (not including all the people who are in prison, on drugs or alcohol or homeless etc for reasons of mental disturbance). We are not talking chickenfeed. Therefore, in order to justify the claim by the director of NIMH, Dr Thomas Insel, that the correct way to approach mental disorder is through the neurosciences, there should be some fairly high-powered thinking on display, right? Er, sorry to say, wrong. There is, in fact, no thinking on display, and that’s what the paper is about.

I surveyed eleven of the most influential psychiatric journals over the eleven calendar years 2001-2011 to see if the claim that mental disorder is brain disorder has ever been proven. That yielded something like 19,500 original papers spread over about 150,000 pages. It would have been more but by that stage, I was absolutely sick to death of reading even the titles of the papers so I didn’t bother with either the Australian and New Zealand Journal of Psychiatry or the Canadian Journal of Psychiatry. I know full well that they have absolutely no idea that scientific claims need to be justified (believe it or not, the CJP still touts itself as advancing the biopsychosocial model) so I didn’t include them. There was nothing in any of those 150,000 pages that could possibly be taken as a justification of the claim that mental disorder is necessarily biological in nature. Nothing. Not a word.

Further, it would seem that there is not even an awareness that a claim of this nature needs justification. It is as though the most senior psychiatrists from all over the world don’t understand that the major claims underlying a scientific program actually have to be proven. I concluded that biological psychiatry is nothing but an ideology, i.e. “a set of beliefs that is false, misleading or held for the wrong reasons but is believed with such conviction as to be irrefutable.” Worse, the people who are pushing it “…use rhetorical language to present an excessively simplified and one-sided view of a complex question in such a manner as to induce people to think that the matter has been resolved when, in fact, it has not.” That is, while failing the criteria for scientific literature, they satisfy the definition of propaganda.

Hmm. This is a turn-up, isn’t it. It seems that our academic psychiatrists (“key opinion leaders”) are nothing but a bunch of propagandizing ideologues. No wonder they didn’t want to publish the paper. Well, you can see the whole thing in a few months in Ethical Human Psychology and Psychiatry and decide for yourself whether there is a science of biological psychiatry or whether it’s just a big con job. I think the answer is very clear.

Some of the papers I saw cited as their authority a book published in 1984 which I’d never read. “The Broken Brain: the biological revolution in psychiatry” was written by Nancy Andreasen, a very influential figure until she retired a few years ago. She was heavily involved in the DSM-III right from the beginning and was editor of the American Journal of Psychiatry from about 1992-2005. It seemed to me that if the argument in favour of biological psychiatry exists anywhere, it would be in this book. Wrong again. It’s not there. She simply states, over and over again: Mental disorder is biological, it has nothing to do with families or spouses, it isn’t your early life experiences, it’s your biology. She does not give any authorities for this but repeats it in dozens of different ways, probably several hundred times throughout the book. That’s nice for all the women who thought they were depressed because their drunk husbands were punching their heads in, or all the children who thought their brawling parents were getting them down. Nice for the drunks and brawlers, too, as she specifically says: No guilt.

The book itself is written in the breathless prose beloved of the medical writers in the Sunday papers who are trying to get their bored readers excited over yet another dramatic “breakthrough.” From beginning to end, page after dreary page, it is stuffed full of errors, innuendos, misleading associations, deceptive claims and outright nonsense. It was all I could do to dredge on and not hurl it out the window. But, from the historical point of view, it is interesting because it shows a number of points about the propaganda war being waged by the NIMH and their friends in the drug industry. On p36, she says: “Manic disorder… that may alternate with depression, is relatively rare and affects only 0.5 to 1% of the population.”

That’s interesting, because in the thirty years since she wrote this book, the incidence of this allegedly genetic disorder has exploded to something like 6% of the population [1], 600-1200% increase in one generation. Wow, something’s happening there. You’d think all those biological psychiatrists and geneticists would be frothing at the mouth to research this epidemic and come up with the “cause.” Surely that would be worth a Nobel Prize or two? Apparently not. Robert Whitaker has set out his case inAnatomy of an Epidemic: a sizable proportion of this rise is caused by the drugs used to treat bipolar and other psychiatric disorders (mainly stimulants and antidepressants). When coupled with loosening diagnostic boundaries and clinical ignorance of the definition of “manic” the effects and side effects of these medications are being misconstrued for bipolar disorder. Somehow, I don’t think that’s the answer they want, so he may not get an invitation to Stockholm this year.

Next question: Why are so many people getting these drugs? Well, that’s what I focus on. My answer is that, because psychiatry doesn’t have a model of mental disorder, its diagnostic standards are so sloppy you could diagnose your dog with a mental disorder. As soon as the diagnosis is made, out come the prescription pads and doggie is on drugs for life. Doesn’t matter whether you have been treating her like a dog, as they say, doesn’t matter whether she was growled at in the kennel when she was little or whether she was bullied at obedience school, mental symptoms = biological disorder = drugs.

Andreasen’s book is strange because some of the little case histories she gives are anything but biological. For example, on p65, she gives the story of Greg, an IT programmer with agoraphobia. My reading of it is that is one of the clearest examples of a psychologically-caused phobia you could ever see, I only wish my patients had such clear histories because it would make treatment much easier. Bizarrely, Dr Andreasen doesn’t even see it; his condition is biological and that’s all there is to it. Clearly, her belief preceded the evidence and therefore blinds her to the obvious facts.

We could go on but it’s not worth it. At this stage, the claim that mental disorder derives wholly (or even mostly) from abnormal biology in the brain has no more scientific support than it did a generation ago, meaning practically none. There are mountains of papers claiming to establish this link but the proof is in the details, and the details show that while these findings are not due to chance (ie p<0.05) the magnitude (relative risk, odds ratio, effect size) of these associations is so extremely small they’re useless (see Ioannidis, Why Most Published Research Findings are False PLOS 2005). As Prof. Andreasen, holder of the National Medal of Science for services to medicine, falls for the mistake of thinking that truth can be established by dint of repetition of a falsehood. The so-called biological basis of mental disorder is an ideological claim kept alive only by a constant deluge of propaganda from people who stand to gain most from it. Have a look at the quote from Mark Twain again, and finish with one from Upton Sinclair: “It’s difficult to get a man to understand something when his salary depends on his not understanding it.”

I will may begin answering one or more questions per month in each newsletter given I get some questions. Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month!

It follows the same approach, looking closely at the history of anxiety and how psychiatry saw it before DSM-III came along. It then shows how the incidence of diagnosed anxiety disorders rocketed as more and more of what were once considered pretty normal fears were converted into illnesses. They show how the DSM committees have twisted and turned in their goal to see everything as evidence of brain disorders and they look at the damage it has done to the community. Their approach is that fear is not just a normal part of life, it’s a very important factor in our survival. Fear has intense evolutionary significance as it is one of the most powerful factors that kept our protohuman ancestors alive rather than ending up as some bigger animal’s breakfast. All moving creatures have an internal warning system that alerts them to danger and gets them ready to deal with it, either by slugging it out or by nicking off.

Horwitz and Wakefield, who are sociologists, argue that many cases of what biological psychiatry sees as illnesses are just examples of the brain doing what it has been programmed to do by millions of years of evolution. I think their case is extremely powerful. However, it suffers from one crucial point: unlike their first book, they don’t actually have a model of anxiety disorders in mind. They are unable to say where normal anxiety stops and mental disorder takes over so they end up in the same position as the biological psychiatrists, saying “Well, this is what we believe, so you better believe it too.” Regrettably, even sadly, it just doesn’t quite work. Parts of the book are very good, but parts of it read like a Me Too book, as in, “We’ve done depression, why don’t we do anxiety as well? OK, so where do we start?”

There are two models of anxiety conditions they should have included. The first is the acute anxiety state, where a person becomes so agitated that he just cannot function. He is shaking and sweating, his heart is thumping, he is about to vomit, he can’t breathe or string two words together and so on. Yes, this is the body doing exactly what it was programmed to do by evolution but no, it isn’t helping him function, especially if it was brought on by a frog or by needing to give a speech at his brother’s wedding. The correct model here is the Yerkes-Dodson curve of acute arousal. Damaging over-arousal may be brought on by a fire, or by seeing his children in danger, but it is still physiologically normal. That’s the first point.

The second is where a person develops disabling fear just by some trivial matter. Horwitz and Wakefield try to hammer these into their evolutionary model but it doesn’t work: the vast majority of panic states have no evolutionary significance at all. They didn’t allow for these problems being a product of a normal brain (i.e. no chemical imbalance whatsoever) caught in a self-reinforcing loop of fear leading to further fear. They wanted to show that anxiety should properly be seen as a natural function but couldn’t allow for the fact that humans aren’t just baboons on the veldt reacting to the sight of a leopard. We have cognitive capacities that baboons don’t have, and we can therefore tangle ourselves in self-fulfilling prophecies that amount to a “disease” state (dis-ease) but are not thereby biochemical diseases of the brain.

The problem for anybody reading their new book is that, by refusing to admit there may be something else beside brain disease and evolutionary arguments, they had to push the evidence in directions it really shouldn’t have gone. I would think that anybody who isn’t already familiar with the manifestations of anxiety may get a bit lost in this book, unlike their first, which was outstanding in its clarity. However, it is still in a league of its own when compared with the usual tripe out of APA Publishing, which tries to say that every twinge of fear is a biochemical disorder of the brain. No it’s not, but nor is it necessarily just a matter of evolution. There is a lot of room between these two extremes, and it’s where most anxious people find themselves.

For details of the Yerkes-Dodson curve and of anxiety as a recursive problem, see Chap. 14 in my 2007 book, Humanizing Madness and also take a look at Diamond et al, The Temporal Dynamics Model of Emotional Memory Processing (FREE!!!), 2007, Neural Plasticity. The section in my book is more tailored to the arguments above but the Diamond paper provides the best overall review of the Yerkes-Dodson curve I’ve seen and should definitely accompany my chapter. Their paper is quite a marvel with a massive total of ~450 references (13 out of 33 pages are references)!

If anybody has a book they wish to recommend, let me know (better still, write a hundred words on why you liked it and I’ll post it).

Good morning, this is the second of what I hope will be reasonably regular newsletters directed at the evolving biocognitive model of mental disorder, the goal being to provide a valid alternative to the current mess in psychiatry. Is psychiatry a mess? Well, Dr Alan Frances certainly thinks so. His blog for Psychiatric Times on December 3rd was entitled DSM-5 Is A Guide, Not A Bible-Simply Ignore Its 10 Worst Changes. Good advice.

I’ve been saying for decades that psychiatry is a mess, my main criticism being that psychiatry fails every known test of what constitutes a science. The core reason is that it doesn’t have a model of mental disorder. What is a model of mental disorder? Well, it’s rather like the idea that if you give antibiotics to a person, you have in your head a concept of what certain disease states are, that is, you have a model of their nature. If you give antibiotics to a person with cellulitis, you are doing so because you accept the model that there are microorganisms out there but, if they get in here, they can cause trouble, i.e. you accept Pasteur’s germ theory of the causation of sicknesses.

Over the years, we have expanded that particular model to include viruses (fast and slow), fungi, protozoans and other nasties, but Pasteur’s basic model remains intact. We have lots of other models of disease, of course, including congenital, traumatic, degenerative, neoplastic, autoimmune and so on. All of these constitute distinct clusters of illness with characteristic causative mechanisms. When students begin medical school, they learn about the normal processes of physiology, then learn how these can be deranged by a variety of causes. Knowing the exact pathology allows a definitive treatment program tailored for each model of illness and tweaked for each individual case.

These days, orthodox psychiatry trumpets that they have the secrets of mental disorder nailed. It is only a matter of time (and money) before their laboratories begin to pour out answers to ancient questions, and humanity can ascend to new levels of mental well-being. Indeed, reading the frequent opinion pieces by the Director of the US National Institute of Mental Health, Dr Thomas Insel, you could be excused for thinking psychiatry is only taking its collective breath before smashing through the barriers to a golden future (search Insel TR on PubMed, he churns out about fifty papers a year). Dr Insel (who is a neurophysiologist, by the way) often says things like “Mental disorder is brain disorder. Everything we need to know about mental disorder will be revealed by the ordinary processes of laboratory science.”

This, of course, is pure rubbish. There isn’t going to be a breakthrough in psychiatry in any laboratory, just because mental disorder is not the sort of thing that can be sorted out using scans or gene sequencers. How could such a highly-qualified, highly-paid person as DirNIMH make such a catastrophic error? Easy: he doesn’t have a model of mental disorder. He thinks he does, but he doesn’t. He’s not alone: I’ve just had yet another critical paper rejected by yet another prestigious journal but the reviewer was quite explicit in rejecting my criticism: “I don’t need a model of mental disorder to know that antidepressants work, just as I don’t need a model to know that antibiotics kill bugs.” I don’t know who he was but he is clearly a complete fool: if he didn’t have an implicit model of certain illnesses being the result of invasion by microorganisms, he wouldn’t use antibiotics in the first place. QED. He would use blood-letting, or seances, or diet or something, but not something that kills bugs. Everything we do is done in the implicit belief that it will work, meaning we only use bugkiller when we think bugs are the problem, i.e. we have a model of illness as caused by bugs (the outstanding success of this “bacteriological” view of illness has been integral in our acceptance of biological psychiatry as shown in Dr David Healy’s The Antidepressant Era).

Before Pasteur’s revolutionary work, there had been attempts to prevent infections, even though people didn’t know that was what they were. The tragic hero, Ignaz Semmelweiss, discovered that if obstetricians washed their hands in hypochlorite after they had performed autopsies, the death rate from puerperal fever plummeted. However, the establishment didn’t see it that way: they were convinced that disease was the result of an imbalance of humours, the Hippocratic model. They refused to accept that contagion could be spread by the tiny bits of putrescent material under the fingernails: How could anything so small kill a healthy person? It didn’t make sense to them in terms of their model, so they rejected it. They thought they could discover the cause of puerperal fever by doing more autopsies, so they ended up killing more women. The doctors could not accept that illness could be caused by their own dirty hands.

So it goes with mental disorder: when mainstream psychiatrists look at the mentally troubled, they don’t see people in pain, they see cases of deranged biology which need to be shoved in increasingly overlapping diagnostic boxes. And, as every fool knows, deranged brain enzymes or chemicals can only be fixed by drugs, certainly not by talking or (ha ha) by sympathy. Dr Insel himself isn’t above mocking the idea that mental disorder could have psychological causes. How does he explain post-traumatic states? Chemical imbalance of the brain. Personality disorder? Chemical imbalance of the brain. Depression? Chemical imbalance of the brain. If everything can be explained by the same cause, then it isn’t an explanation at all.

In fact, Dr Insel has recently seen the error of his ways and has now proclaimed that mental disorder isn’t due to deranged chemicals, it’s due to deranged brain circuits, whatever they are. However, the solution is the same: More laboratory research, more scans, more genetic tests, more drugs. That his solution may be part of the problem hasn’t yet occurred to him or any of his supporters. We will talk about this more.

Retribution:

In early December, a French court convicted a psychiatrist of manslaughter and sentenced her to twelve months in prison, plus a fine of about $11,000, after one of her patients murdered his elderly stepfather. She was found guilty on the basis that she knew her patient was dangerous but did not detain him in hospital (the prison sentence was suspended but remains in place). Just recently, the first of what promises to be many claims was lodged against the psychiatrist who saw the Aurora (Colorado) killer, James Holmes. The basis of the claim is that she knew her patient was dangerous but did not detain him in hospital.

I see these claims as destructive for two reasons. First, they assume something about the psychiatric process which is factually false, and second, they will have far-reaching, adverse effects on mentally-troubled people. The false assumption is that psychiatrists (or anyone, for that matter) can reasonably predict homicide (or suicide etc). No, we can’t. These events are so rare that no person or profession can claim to have a formula that allows the prediction to be made. For example, about half my patients express suicidal ideas when I first see them. In thirty years, not one of them has subsequently committed suicide, so forcing them all into hospital would have been a) pointless as they weren’t in danger, b) logistically impossible, c) very destructive to them, d) a denial of their rights and e) outrageously expensive, not to mention getting me a reputation as somebody who panics at the mention of suicide. People who say, “Oh, he should have been admitted to hospital” have obviously never tried ringing a mental hospital at night to get somebody admitted.

The adverse effect (The Law of Unintended Consequences) is that psychiatrists will now be far more inclined to reach for the committal orders than before. Err on the side of caution, that’s what they will say; if in doubt, lock him up. So more and more people will be detained, on less and less evidence, for longer periods, to get more drugs and ECT and, once in the system, they tend to never get out. I get a regular stream of emails from people, saying things like: “I agreed to go to hospital six years ago after I took an overdose, and they still have me under an order. I have to take drugs, I can’t leave the town, my money is sequestered, I can’t move, they come into my home at will, I can’t drink or even go into a bar. I have no life. Please help me get my freedom back.” But when being detained drives people to violence or suicide attempts, that is taken as proof that they need further detention, not as proof that they shouldn’t have been there in the first place.

Bizarrely, many people in this country are subject to continuing treatment orders on the basis of the risk of “reputational damage.” What this means is that if they don’t get the drugs, they will automatically go crazy and automatically damage their reputation. Nothing is automatic, not even homicide, and what reputation is left to a person who has been in the system for six years? The system is now sillier than any of the people it is supposed to be helping. Making psychiatrists responsible for their patients’ (occasional) crimes will only make matters worse for the vast majority of mentally-troubled people who never commit crimes.

On the other hand, last month saw the totally unnecessary death by suicide of the archetype of the nerdish computer genius, Aaron Swartz. The story is complicated but briefly, this brilliant but very erratic young man was charged with stealing after he downloaded millions of academic papers from an archive and made them available to the public. He faced 35yrs in prison for an offence that was no longer: the archive subsequently released them anyway. The case was pursued by the Massachusetts Federal Attorney, Carmen Ortiz and her assistant, Stephen Heymann, who took an intensely personal and hostile stance on what most people saw as little more than an undergraduate prank. The threat of imprisonment was too much for Swartz, who couldn’t comprehend the venom behind the prosecution.

What we can be sure of is that Ortiz and Heymann will not be held responsible for their actions. They will say (and Ortiz’s husband already has said on her behalf) “Oh no, it was his decision to kill himself, it had nothing to do with us.” So when governments actively drive people to suicide or homicide, that’s nothing and they don’t have to improve, but if psychiatrists don’t act to prevent suicide or homicide, that’s really something. The net effect is that, for the mentally troubled, the noose tightens and life will get that little bit worse.

Interestingly, my computer has been attacked by a virus this week (I use Linux and keep up to date so it’s normally not a problem). Somebody running advertising programs hacked in and stole my email address list, then sent spam to all of them. I’ve had several spurious emails this week from people I know, all spam from companies that use the NBC logo. Can I be assured that these pests will be hounded to death by Ms Ortiz and pardners in the pursuit of cyberjustice? I won’t hold my breath.

I will try to publish comments etc. but please keep them brief and reasonably polite.

As always, I cannot give any psychiatric advice to any person for any reason.

I will begin answering one or more questions per month in each newsletter. Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month!

In Comorbidity Missed, Zimmerman’s sample was an outpatient clinic made up of fee-for-service patients including Medicare but not Medicaid. 500 randomized patients were assigned to either SCID (long structured interview) or semi-structured interview (“routine” in their words). 96% of the “semi-structured” group were interviewed by psychiatrists. The combined samples (500 & 500) were approximately 60% female, 93% white, 64% some college, and 48% married with an average age of 39.Of the 500 regular interviews only ~200 anxiety disorders were diagnosed whereas SCID had ~550 (out of 500)! What is important to note is that the number of mood disorders were about the same between the two diagnostic arms (~350 each). Social (16 vs 143) and specific (4 vs 52) phobias had some of the highest rates of underdiagnosis. Zimmerman also has many other excellent papers regarding borderline personality disorder being misdiagnosed as bipolar disorder (see 2011 FREE!and 2010). They showed that “40% (20/52) of the patients diagnosed with DSM-IV borderline personality disorder reported having been misdiagnosed with bipolar disorder compared to slightly more than 10% (62/558) of the patients without borderline personality disorder.”

I wrote a bit about this paper in chapter 16 of my new book, The Mind Body Problem Explained;
“A huge and long-term study from British Columbia looked at 937,943 children who were between six and twelve years of age at any time between December 1st 1997 and November 30th 2008. This compared the child’s month of birth with the risks of acquiring the diagnosis of ADHD and of being treated with stimulants, for boys and for girls. Methodologically, the study appears very sound. The researchers found that the risk of the diagnosis for boys born in December, the last month of the academic year, was 30% higher than for boys born in January, while for girls, the increase in risk was an astounding 70%. This means that children born in the month of December were at much greater risk of having a “genetic illness” than children who dragged their feet and arrived in January. Similarly, the risks of being prescribed stimulants was 41% higher for December boys while, for girls, the increase in risk was a completely improbable 77%. In boys, the rates of diagnosis and prescription were approximately three times those in girls. Boys, of course, are physically more active than girls and verbally less proficient until well into adulthood, differences which are never entirely obliterated in the community.” The best way to see this paper is to follow this link.

In Boston, I met Bob Whitaker again, author, investigative journalist and concerned person. I am a great fan of his and firmly believe his book, Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill (New York: Perseus Books, 2002), should be required reading for all medical students and residents, not to mention psychologists, social workers, psychiatric nurses and caring citizens. It outlines the history of the “treatment” of mentally disordered people in the US, from the earliest hospital in Pennsylvania in 1751, to the present.

The constant theme is that, despite 250 years of “progress,” the outcomes of treatment for mental disorder in the US are now actually worse than they were in the past. Unfortunately, the psychiatric mainstream reacted very badly to his work, but he is a meticulous researcher and nobody has been able to fault his case in this book. Highly recommended.

There are heaps of good books available, it’s hard to keep up with them, but I have to mention Martin Whitely’s Speed Up and Sit Still: the controversies of ADHD diagnosis and treatment. (University of Western Australia Press: Perth, WA, 2010). Martin Whitely is not a psychiatrist, and not even medically trained, yet he has become an expert on the question of the inappropriate applications of psychotropics in schoolchildren. He worked as a schoolteacher, then entered the WA Parliament after becoming alarmed at the drugging of an entire generation. His very readable book charts the history of the “epidemic” of ADHD and shows how the epidemic was arrested and reversed in WA. First place in the world. If it can be done there, it can be done anywhere.

If anybody has a book they wish to recommend, let me know (better still, write a hundred words on why you liked it and I’ll post them).

I have just returned from an exhausting trip to the US to launch my fifth book, bravely entitled The Biocognitive Model for Psychiatry: The Mind-Body Problem Explained. The title comes from Dennett’s book from 1991, titled Consciousness Explained, in which he emphatically did not explain consciousness. I hope I haven’t fallen into his trap. I think the biocognitive model of mind-body interaction goes a long way to showing exactly how an informational state called the mind can interact with the physical machine called the body, but the final decision rests with the readers.

I spent a couple of days in Los Angeles at the Harbor-UCLA Medical Center, in Torrance, South LA. This is the main public hospital for a huge swathe of the city, a flat and rather featureless area of mixed industry, run-down public housing, working class areas and gently ageing beachside suburbs. In fact, it’s exactly the sort of hospital I like and it was very interesting being there. What quickly became clear during this visit is that psychiatry is facing a generational crisis. There seems little doubt that medical students and psychiatric trainees (residents) are getting sick of the standard approach dished out by the orthodox psychiatry and I found the training the residents receive at Harbor amongst the most forward-thinking I’ve seen. I found it very encouraging, as I’ve been sick of the status quo for nearly forty years. Trouble is, most trainees don’t know the full extent of what else is available, mainly because orthodox psychiatry makes sure they don’t get to hear of alternatives. All too often, I hear people say, “But how can you talk about a model of dualist interaction? Isn’t dualism just magical thinking?”No, it’s not.

The notion that a dualist model of mind necessarily means magical thinking is part of the 1960s prejudice. We won’t go into all the details, but most people trained before about 1990, meaning most professors today, were totally flooded with the idea that science is not about unobservables, and the mind is unobservable, therefore science can never be about minds. From this came behaviorism and biological psychiatry. Behaviorism imploded somewhere about 1985, but biological psychiatry hangs on, the last outpost in the world of people who firmly believe they can sort out a person’s mental problems by reducing their distress to brain scans and clinically insignificant genetic defects.

The modern generation, meaning anybody born from about 1980 on, doesn’t have the slightest difficulty with the idea that the mind can be seen as an informational space generated by the brain. They (young people) think in terms of hardware and software, and it never occurs to them that talking about software is equivalent to talking about magic. So there is a very large gulf opening up between the generations. In the blue corner (conservative), we have the Old Brigade, firmly committed to the idea that their science must exclude all talk of minds on the basis that it necessarily implies magical thinking. In the red (radical) corner, we have the rising generation, who are sick of being told that everything is a chemical imbalance or genetic lesion, and want to return to the idea of psychiatry as a human-centered discipline.As an example, I saw a senior psychiatrist (in a town I won’t name) interview a new patient. He knocked it over in 19 minutes. That is correct, less than twenty minutes. In twenty minutes, I’m not even through the first part of my standard interview! It takes me an absolute minimum of an hour to get a history, and I push people hard so we can get to the serious stuff. In order to keep to his time schedule, the psychiatrist dispensed with all that bothersome talk about how patient was feeling and what he thought had gone wrong in his life.